A multicomponent psychosocial intervention among people with early-stage dementia involving physical exercise,cognitive stimulation therapy,psychoeducation and counselling: Results from a mixed-methods study

Abstract

Background

There is increasing awareness of the benefits of both physical and psychosocial interventions to empower and benefit people with dementia and their caregivers. However, the potential additional benefits of combining physical and psychosocial interventions have only been sparsely explored. The aim of this pilot study was to investigate the acceptability and potential impact of a multicomponent intervention comprising physical exercise, cognitive stimulation therapy (CST), psychoeducation and counselling for people with early-stage dementia.

Design

A 15-week multicomponent group-based intervention was offered to people with early-stage dementia in Denmark (N = 44). A mixed-methods design combining interviews, observations, tests of cognitive and physical functioning and an interviewer-assisted questionnaire on quality of life was applied to (1) investigate acceptability of the intervention, including whether people with dementia and their caregivers found the intervention meaningful and (2) to explore and assess changes in participants’ physical and cognitive functioning and quality of life. The study was conducted between June 2018 and August 2019.

Results

The pilot study demonstrated that the multicomponent intervention was acceptable for people with early-stage dementia and their caregivers. Test results did not show significant changes in measures of participants’ physical and cognitive functioning or quality of life. However, qualitative data revealed that participants perceived the intervention as meaningful and found that it had a positive influence on their physical and social well-being. In addition, interaction and support from peers and staff members was considered important and rewarding.

Conclusion

This multicomponent intervention constitutes a meaningful and beneficial activity for people with early-stage dementia and their caregivers. It provides an opportunity to engage in social interactions with peers and experience professional support. The study also underlines the importance of providing prolonged and sustainable interventions for people with dementia to maintain personal and social benefits.

Keywords

dementia group based multicomponent intervention physical exercise cognitive stimulation therapy psychoeducation counselling mixed methods social health

Introduction

About 50 million people live with dementia worldwide, and the number increases by nearly 10 million new cases each year (World Health Organization, 2020). Dementia is an umbrella term for more than 200 different brain diseases, with Alzheimer’s disease being the most common course of dementia, accounting for 60–70% of all cases (ibid.). Dementia diseases are characterised by cognitive impairments, and emotional, social and behavioural symptoms are also common during the progressive course of most dementia diseases. The needs of people with early-stage dementia differ depending on the individual; however, there are some similarities in terms of how to preserve well-being and enhance independence, for example, engaging in social and physical activities, and feeling supported by others (Brataas et al., 2010; Telenius et al., 2020; von Kutzleben et al., 2012). Currently, there is no medical treatment available to cure dementia or substantially alter disease progression. However, a growing body of evidence shows that various specific non-pharmacological interventions can support and improve the lives of people with dementia and their families (ibid.).

One approach is physical exercise, which has shown promising results in regard of improving physical capacities such as strength, performance and exercise self-efficacy (Lee et al., 2016; Sobol et al., 2016; Telenius et al., 2015). Moreover, being physically active can improve performance of activities of daily living, reduce depressive symptoms and thereby enhance quality of life among people with dementia (Henskens et al., 2018; Huang et al., 2020; Junge et al., 2020; Nuzum et al., 2020; Potter et al., 2011).

Another approach is group-based cognitive stimulation therapy (CST), which has gained acceptance as a non-pharmacological psychosocial intervention providing general stimulation of cognition function of people with dementia, aiming to maintain and if possible improve these abilities (Lobbia et al., 2019; Woods et al., 2012). Cognitive stimulation therapy provides structured and versatile stimulation of the cognitive functions of the brain. The method builds on several principles, including mental stimulation, the use of reminiscence, stimulation of language, as well as a focus on building social relationships and promoting reality orientation (Spector et al., 2003). Research has generally demonstrated that CST can maintain, and to some degree improve, cognitive functions among people with mild to moderate dementia, for example, memory and attention. In some studies, enhanced quality of life and well-being have also been demonstrated (Aguirre et al., 2013; Chao et al., 2020; Woods et al., 2012).

Self-management approaches are offered to promote self-efficacy and capacity to cope with and manage health conditions, and they often involve elements of education, counselling and peer support (Barlow et al., 2002; Mountain, 2006). Such approaches are well-established for many chronic health conditions, but not established as a common intervention for people with dementia (Huis in het Veld et al., 2020; Quinn, Toms, Anderson et al., 2016a). There is, however, increasing awareness of the request for self-management interventions among people with early-stage dementia (Mountain and Craig, 2012; Toms et al., 2015), and a growing body of evidence of the benefits of self-management interventions to promote coping, adaption and well-being when living with early-stage dementia (Martin et al., 2015; Quinn, Toms, Jones et al., 2016b; Sørensen et al., 2008a; Øksnebjerg et al., 2019). Such interventions are traditionally delivered as singular therapeutic approaches and from a research perspective it can be argued that single interventions are easier to categorise and compare (Woods, 2021). However, to meet individual and diverse needs of people with dementia, including a frequent request for the most effective combination of therapies, it is important to also explore potential benefits of combined interventions. Previous studies addressing multimodal non-pharmacological interventions for people with dementia generally show potential cumulative effects of combining several interventions, for example, physical, cognitive, psychological and psychosocial interventions (Chalfont et al., 2020; Karssemeijer et al., 2017).

To our knowledge, no previous studies have explored a group-based multicomponent intervention for people with early-stage dementia comprising physical exercise, CST and self-management activities involving psychoeducation and counselling. This pilot study was conducted to investigate acceptability and potential impact of such a multicomponent intervention for people with early-stage dementia. The study had two objectives: (1) to investigate acceptability of the intervention, including whether the participants and their caregivers found the intervention meaningful and (2) to assess changes in participants’ physical and cognitive functioning and quality of life. The study was conducted between June 2018 and August 2019.

Methods

Participants and setting

Participants in the intervention were recruited among citizens in the Municipality of Copenhagen in Denmark. Information about the intervention was disseminated through various public health and social authorities, for example, memory clinics, general practitioners, home-care staff and dementia consultants. Potential eligible participants received written information and were subsequently contacted by telephone and invited to a screening interview with staff conducting the intervention. To be included in the study, participants had to have a clinical diagnosis of dementia according to the NIA-AA criteria (McKhann et al., 2011) and be at an early stage of their dementia disease. This was assessed based on a screening interview between the participant and staff running the intervention. To be eligible, participants also had to be able to manage transportation from home to the intervention site independently, to be motivated to engage in group sessions with other people with dementia and to be able to participate in moderate to rigorous physical exercise. These criteria were assessed based on the participant’s self-report and staffs’ assessment of the person’s cognitive and physical ability based on initial conservation and a walking tour around the centre. The intervention took place at the Centre for Dementia, which is a specialised centre in the Municipality of Copenhagen offering counselling and various activities for people with dementia and their caregivers.

Intervention programme

The intervention was group-based with two weekly training sessions of 3 hours duration over the 15-week period (30 sessions in total). Each group consisted of 7–10 participants. All 30 sessions comprised a 1½-hour physical exercise programme, and this was either combined with 1 h of CST (27 sessions) or 1 h of psychoeducation (3 sessions). All sessions involved a 30-min break where participants could change clothes, have refreshments and take part in informal talks with peers and staff members. In addition to the group-based sessions, participants were also offered three individual counselling sessions. Caregivers were offered to participate in two separate three-hour psychoeducation group sessions for caregivers. They were also invited to join the individual counselling sessions together with the person with dementia. See Table 1 for details on activities, participants and setting during the intervention programme.

Table 1.

Activities, participants and setting during the intervention programme.

Activity	Activities for people with dementia	Caregiver involvement	Setting and staff
Physical exercise	30 1½-hour group exercise sessions with moderate to high intensity. Activities included: Warm-up (15 min) Cycling (20 min) Short break (5 min) Strength exercise and dual-task exercises (40 min) Relaxation (5–10 min)	No involvement	Physical exercise took place in a workout room and was led by two physiotherapists
Cognitive stimulation therapy	27 1-hour group sessions conducted according the principles of CST. Each session had a predefined theme, for example, food and meals or work life	No involvement	CST sessions took place in a group room and was led by two occupational therapists
Psychoeducation	Three 1-hour group sessions addressing the following themes: • Information on dementia diseases • Everyday life with dementia • Legal topics and planning future living and care • Introduction to further activities and support for people with dementia living in the city of Copenhagen	Two 3-hour sessions for groups of caregivers, addressing the following themes: • Information on dementia diseases • Everyday life with dementia • Legal topics and planning future living and care • Introduction to further activities and support for people with dementia and caregivers living in the city of Copenhagen • Communication with a person with dementia • Being a caregiver to a person with dementia	Sessions took place in a group room and was led by a dementia specialist counsellor
Counselling	The participants were offered three individual counselling sessions based on their current needs	Caregivers were invited to participate in the sessions	Counselling session took place in a meeting room and was led by a dementia specialist counsellor
Visit to a showroom apartment with dementia-friendly interior design and facilities	Two CST group sessions were replaced by a visit to an apartment with dementia-friendly interior, designs, and facilities. During the first visit, participants shared personal experiences on creating a dementia-friendly home, while participants were introduced to various dementia-friendly technologies during the second visit	Participants and caregivers were encouraged to explore the apartment and its technological and practical solutions on their own or accompanied by an occupational therapist	The showroom apartment was located at the Centre for Dementia and visits were guided by an occupational therapist

Data collection

Outcome measures

Demographic information was collected at baseline, together with pre-intervention measures. Post-intervention measures were obtained on the last day of the intervention for each group.

Physical functioning was measured using three tests: 30-s chair stand test assessing lower body strength (Blankevoort et al., 2013; Jones et al., 1999), 10-m walk test single-task and dual-task, both assessing usual gait speed (m/s) on a 10-m long course (Sobol et al., 2016). Dual-tasks were assessed by adding a test of cognitive performance (counting backwards from 100 by oneself aloud) to the 10-m walk test (Montero-Odasso et al., 2009). Cognitive functioning was measured using the Mini Mental State Examination (MMSE) test (Folstein et al., 1975), where performance is summarised in a score ranging from 0–30, with 30 being the highest score. Participants’ quality of life was measured using the Quality of Life in Alzheimer’s Disease (QoL-AD) scale (Gibbons et al., 1999), which is an interview-assisted questionnaire. Attendance rate was also registered to support the assessment of acceptability. All tests were conducted and reported by the staff who conducted the intervention at the Centre for Dementia. Staff members received rater training prior to the study.

Interviews and observations

Observations and interviews were conducted to investigate how participants and caregivers experienced the intervention and how it influenced their everyday lives. Two groups consisting of 14 people with dementia (13 men and one woman) and 13 caregivers (eight spouses and five adult children) were involved in interviews and observations. The two groups were randomly selected according to the timing of the qualitative data collection. Interviewees for individual interviews were selected using convenience sampling and by consulting the staff to avoid compromising personal circumstances of the participants and/or their caregivers. We included caregivers in the qualitative part of the study to explore their response to being involved in the intervention and to gain knowledge by proxy on how the intervention had affected their spouse or parent. All interviews were conducted by one or two experienced researchers who were not involved in intervention delivery. The following data were collected from 12 December 2018 until 22 May 2019:

• Six observations of physical exercise and CST sessions, each lasting 3 hours (at the beginning, middle and end of the 15-week period).

• Two observations of psychoeducation sessions with caregivers and participants, respectively.

• Two focus group interviews with participants (a total of 13 participants).

• Two focus group interviews with caregivers (a total of seven caregivers).

• Four individual interviews with caregivers, including three over the phone and one double interview (a total of five caregivers).

• Four interviews with participants and caregivers in their own home 2 weeks after completion of the intervention (a total of four participants and four caregivers).

• During observations, the researchers followed an observation guide focussing on interactions between and among participants, caregivers and staff, as well as the physical surroundings and intervention activities, for example, type of activity, duration and reactions or attitudes towards each activity. Throughout the observations, one or two researchers were present and took fieldnotes, which were typed out immediately after. Interviews were based on interview guides with semi-structured open-ended questions. Table 2 shows the different themes in the interview guides, which were inspired by a conceptual framework on what constitutes health-related quality of life in dementia, developed by Smith et al. (2005).

Table 2.

Summary of themes included in the interview guides.

In-person interviews with participants	Group interviews with participants	Group interviews with caregivers	Telephone interviews with caregivers
Daily activities	Opinions about and experienced benefit of • Physical exercise • Cognitive stimulation therapy • Psychoeducation lessons • Individual counselling	Opinions about and experienced benefit of • Psychoeducation lessons • Visit to an inspiration showroom apartment • Individual counselling (if they had attended together with their spouse)	How everyday life is affected by dementia
Health and quality of life			Personal benefit from attending the intervention
Cognitive functioning			View upon how the intervention has affected their spouse regarding: • Daily activities • Health and quality of life • Cognitive functioning • Social relationships • Self-image • Thoughts about the future
Social relationships
Self-image	Overall experience of the intervention	Overall experience of the intervention
Thoughts about the future	Improvement proposals for the intervention	Improvement proposals for the intervention

Data analyses

Quantitative data were analysed using IBM SPSS Statistics v.22. Baseline characteristics were explored with descriptive statistics. Possible changes in outcome measures were investigated through non-parametric analysis of change scores (Wilcoxon signed-rank test). Tests of significance were performed two-tailed, with a significance level of 0.05. Imputed values for missing data were calculated following standard procedures for multiple regression modelling.

All interviews were auto recorded and transcribed verbatim and analysed using thematic analysis, which is a method for identifying, analysing and reporting patterns (themes) within data (Braun and Clarke, 2006). First, the transcripts were read thoroughly to get familiar with data and to identify repeated patterns of meaning (codes). Two of the authors (xx and xx) independently analysed the transcripts and a random sample of transcripts was analysed by a third author (xx). Emergent themes were continuously discussed among the researchers at a facilitated workshop to ensure credibility (Nowell et al., 2017). Quotes from interviews and insights from observations are used to illustrate each theme. The qualitative analysis was carried out using Nvivo software 12.

Ethical considerations

The study was approved by the University of Southern Denmark in accordance with the Danish Data Protection Regulation (No. 10.103, date of approval October 9th, 2018) and conducted in compliance with The General Data Protection Regulation (EU) 2016/679 and the principles of the Helsinki Declaration (World Medical Association, 2013). Staff members at the Centre for Dementia signed a written consent after being informed about the study and assured confidentiality in handling all data. Staff members of the intervention informed the participants and their caregivers that participation in the study was voluntary and that they could withdraw at any time without any consequence for current or future help or support from the Municipality of Copenhagen. Both people with dementia and caregivers signed a written consent. During observations and interviews with participants, we asked for their consent to participate once again to ensure process consent (Dewing, 2007).

Results

Characteristics of participants

A total of 44 participants organised in six groups were included in the study, and data from 36 (81.8%) are included here. Five participants dropped out of the intervention, and three participants were lost to follow-up. Descriptive characteristics of the 36 participants are summarised in Table 3. Fourteen participants participated in the qualitative part of the study.

Table 3.

Background characteristics of participants.

Age* (years), mean (SD) (range)		74.4 (6.9) (60–86)
Sex male, n (%)		23 (63.9)
Marital status living with spouse, n (%)		27 (75)
Diagnosis, n (%)
	Alzheimer’s disease (AD)	23 (63.9)
	Vascular dementia (VaD)	4 (11.1)
	Mixed AD and VaD	1 (2.8)
	Lewy body dementia	3 (8.3)
	Other**	4 (11.1)
	Unknown	1 (2.8)

*Information on age is missing for one participant (n=35).

**Other: for example, Parkinson’s disease with dementia and unspecified dementia diagnosis.

Changes in outcome measures

As shown in Table 4, no significant differences were found between baseline and post-intervention measures of cognitive functioning (MMSE), quality of life (QoL-AD) and the three physical tests (chair stand test, 10-m walk test single- and dual-task).

Table 4.

Changes in outcome measures from baseline to post-intervention.

Measure (max score)	Baseline mean (SD) (range)	Post-intervention mean (SD) (range)	p-value
MMSE^a	23.6 (4.57) (13–30)	23.7 (4.04) (11–30)	0.96
QoL-AD^b	39.7 (6.6) (23–52)	40.7 (5.4) (31–51)	0.36
30s chair stand test^c	14.7 (5) (9–29)	14.2 (4.3) (8–28)	0.69
10-m walk test (single-task)^d	8.5 (1.4) (4.6–12.2)	8.6 (1.8) (5.6–13.7)	0.70
10-m walk test (dual-task)^e	12.7 (6.8) (1–42)	14.2 (7.5) (6.5–42.4)	0.33

^aTotal scores range from 0–30, with lower scores indicating a greater cognitive impairment.

^bTotal scores range from 13–52, with higher scores indicating higher level of quality of life.

^cTotal number of sit-to-stands within 30 s, with higher numbers indicating greater lower body strength.

^dUsual gait speed (m/s) on a 10-m long course.

^eUsual gait speed (m/s) on a 10-m long course, added a test of cognitive performance (counting backwards from 100 by ones).

Acceptability of the intervention

An attendance statement shows that 89 pct. of the 44 participants completed the intervention with an average of 25.5 (out of 30) attendances per participant (data not shown). Reasons for dropping out were lack of motivation or poor physical health (e.g. heart conditions or arthritis). Being together with peers and getting support from caregivers and staff member were motivational factors for the participants' retention in the intervention.

Psychoeducation, individual counselling and visits to the dementia-friendly apartment were integrated in the intervention to give information, support and inspire participants. Overall, the analyses indicated that these activities were acceptable to both people with dementia and caregivers. According to caregivers, the psychoeducation sessions were informative and relevant to their current life situation. They appreciated that the sessions were given a personal angle by enabling discussion of individual challenges in everyday life with others in the same situation as themselves and with an experienced dementia specialist counsellor. They would miss this personal angle if they solely were to read about the same topics in a book or on the internet by themselves. The participants also expressed that they enjoyed and benefitted from psychoeducation. Some expressed that they gained a better understanding of their own dementia disease and the symptoms they experienced.

‘You have gained an insight into what you’re suffering from. This was explained to us, otherwise you haven’t thought about what Alzheimer’s is’. (Participant 3)

Opinions about individual counselling sessions were more varied. Some participants perceived them as very beneficial in terms of getting professional support for personal challenges, while others could hardly remember attending them. Finally, visits to the dementia-friendly showroom apartment were highlighted as a useful source of inspiration for practical and technological solutions in the participants’ daily lives.

‘It can really be a jungle to find your way through, and I think the fact that they have an apartment where you can get some ideas for aids. Among other things, we bought a watch from the municipality, which was the first thing we borrowed from there [the showroom apartment with dementia-friendly interior design and facilities], so you get inspiration for what can be made easier’. (Caregiver 2)

Participant’s experience and evaluation of the intervention programme

Three main themes comprising 10 subthemes emerged from interview and observational data. An overview is displayed in Table 5 and the themes are described in detail below.

Table 5.

Themes in observations and interviews.

Main theme	Subtheme
1. Physical well-being	Visible changes Opportunity to build or maintain physical shapeProfessional support
2. Cognitive stimulation	Vague purpose of CST No perceived impact A joyful social dimension
3. Social well-being among participants and caregivers	Interaction with peers Doing something meaningful Creation of Structure in everyday life A sense of cohesion

Main theme 1: Physical well-being

Many participants felt that they benefitted from the physical exercise and that it brought about the most positive and apparent results during the intervention period. The exercise sessions left the participants feeling sore and tired, and eventually, a lot of them experienced getting stronger and in better shape.

‘I’m in better shape now. I can almost walk around my park without it hampering me. (…) I can feel that it’s easier for me to bend over and reach something. It’s much easier. I’ve gotten better, I’d say’. (Participant 6)

Those participants who were physically active before the intervention did not notice a substantial impact on their physical abilities. However, they perceived exercise sessions as a good opportunity to maintain their activity level and physical shape. Regardless of whether the participants were physically active in their spare time or not, their motivation for exercising was guided by the professional support they had from physiotherapists and of their awareness of the importance of staying physically active.

Physical exercise was also highlighted as the main reason for many of the participants’ involvement in the intervention in the first place.

‘What I looked forward to the most was the physical exercise so you get your muscles working. It’s supposed to be good for us [people with dementia]’. (Participant 8)

Main theme 2: Cognitive stimulation

In contrast to the physical exercise, participants found CST less meaningful and beneficial. First, they had a hard time grasping the purpose of the sessions, and secondly, they did not notice any improvements regarding their cognitive abilities, for example, memory.

‘After all, it’s quite a short time we have in there [during CST sessions]. It’s very hard to collect something... get something out of it. I hoped that it [CST] was smart [effective] and that it [improvements] came by itself, but when you look at it, 3 months is nothing in one’s life (…). After all, it does not change anything by applying something to the brain. It does not happen from 1 day to another. It just doesn’t’. (Participant 1)

Even though participants enjoyed the calm environment and the social dimension in conversations and cognitive exercises embedded in the sessions, they were not convinced of its intended cognitive impact.

‘Again, just being together... I do not believe that it has been particularly brilliant what we’ve done [during CST sessions], but we’ve done it together and helped each other as much as we could. It’s been really fun, I think’. (Participant 4)

Main theme 3: Social well-being among participants and caregivers

Participants experienced that taking part in the intervention gave them an opportunity to meet peers and be part of a group where they did not have to worry about small cognitive flaws such as talking slowly, forgetting things or repeating themselves. In addition, some also highlighted that doing something active and meaningful provided structure and content to their everyday life. In the following, a caregiver and a participant express how participating in the intervention became a part of a personal narrative in other social contexts:

‘But then, I think that the fact that he can now tell [his friends and family] that he attends activities twice a week at the Centre for Dementia (…) so in this way, he has something to tell (...) I mean, being able to tell some news and it [the intervention] really engages him… then there’s also something to talk about’. (Caregiver 5)

‘A new dimension has turned up in your life. It really has. If you were to make plans with someone, you’d say: ‘Not Tuesday and Thursday’ [when the intervention take place]’. (Participant 2)

According to caregivers, it sometimes seemed easier and more enjoyable for their spouses to spend time with peers in the group instead of family and friends:

‘You are having a good time and you do some activities together. I mean, even though you were together with your close brother the other day and your really good friend, with whom you have been friends since you were 18 years old, and you felt secure [together with them], but somehow it gets a little… quite often it may actually be a little more pleasant for you to spend time with someone who is more equal (…) Well, I mean you laughed more yesterday [together with peers] compared to last Sunday with Paul and Lisa [friends of the family], right?’ (Caregiver 5)

‘Well, you’re right. I can’t really catch what they [friends of the family] are talking about – or not talking about… the ongoing conservations around me. I can’t really keep up with them and you know, I used to be fully capable of that earlier’. (Participant 1)

Spending time and doing activities together with peers created a sense of cohesion among the participants. One participant described it the following way:

‘But you’re right! It’s as if the things which are going on between us [among participants] are kind of slower than the things which are going on around us. This means that you can keep up. You can pretty much keep up with the things which are going on’. (Participant 1)

Staff members generally focused on creating a positive social atmosphere, strived to create social ties and to enhance the personal and professional support embedded in them. This focus on social interactions and group-based experiences was also intended to promote a sense of coherence between the different parts of the intervention.

In some cases, the social interaction with peers also acted as a mirror for the participants, against which they could compare themselves with other participants with regards to cognitive and physical abilities. For some of the participants, it felt encouraging and instilled hope to be around others who had been living with a dementia disease for a longer time and still retained a reasonable level of functioning. On the other hand, it also turned out to be a disadvantage for participants that felt discouraged when meeting somebody with a lower level of functioning compared to themselves, because it reminded them of the disease progression.

Dementia not only affects the person suffering from the disease; the person’s family and other relatives are also severely affected. Several studies have shown that caregivers to people with dementia are likely to feel worn out and have increased risk of both physical and mental illness (Ask et al., 2014; Hiyoshi-Taniguchi et al., 2018; Joling et al., 2010). Analysis of our data showed that caregivers expressed great gratitude for the opportunity to meet others in a similar situation as themselves. This gave them an opportunity to express their frustrations and inspire each other on how to cope with everyday life as a caregiver for a person with dementia. Ultimately, they experienced that they were not the only one in an emotionally demanding situation. A caregiver described the benefits of meeting peers:

‘You listen to others, their opinions and what they have been through and what they are experiencing. I think that’s… for me at least to compare… I think that’s nice. Then you think to yourself: ‘Ah, it’s not just you’ [who are in a difficult situation]’. (Caregiver 3)

As another important benefit, the intervention provided caregivers with a break and personal space twice a week for 3 hours during the time when the person with dementia was away from home to take part in the programme at the Centre. This allowed them to have time for self-care:

‘I get a little freedom. It’s wonderful. The idea that they [the participants] are doing something meaningful, use their bodies, and even drive there [to the Centre for Dementia] themselves. To me it’s been great that he’s doing something himself because I do a lot. It’s important that he also does something and that he takes responsibility for being together’. (Caregiver 4)

There were also a few examples of how participants and caregivers tried to maintain contact and interacted outside the intervention. In one of the groups, caregivers arranged a joint dinner with the participants towards the end of the programme. In addition, participants in the same group were offered to join a physical exercise programme for people with dementia after the end of the intervention. This was run once a week by volunteers. Thus, it indicated that participants could be encouraged to continue having contact with peers from the group and engaging in activities together after the end of the intervention, but it had to be initiated and maintained by caregivers and other supporters.

Discussion

In this study, we found that a multicomponent psychosocial group-based intervention was acceptable and beneficial for people with early-stage dementia. Quantitative outcome measures did not show significant improvements in neither physical or cognitive performance nor quality of life. However, our qualitative analysis showed that participants perceived the intervention as an opportunity to engage in an integrated and meaningful activity which had a positive influence on their physical, mental and social well-being. Participants and caregivers experienced great support from the staff members at the Centre for Dementia and found it beneficial to engage in social interactions with peers. Zooming in on the elements embedded in the intervention, participants perceived some parts as more meaningful and beneficial than others. In relation to physical exercise, participants experienced improvements in terms of endurance and strength. They were more sceptical about CST sessions since they did not experience any cognitive improvements and in general had difficulty understanding the purpose of the sessions. Psychoeducation and individual counselling were also highlighted as beneficial for both participants and caregivers, since the elements were informative and relevant to their current life situation.

To our knowledge, this is the first study to demonstrate that an intervention combining physical exercise, CST, psychoeducation and counselling is acceptable and, to some extent, beneficial to people with early-stage dementia and their caregivers. Attendance to the intervention was high (mean: 85%) and in line with previous studies showing that physical exercise and cognitive stimulation is acceptable components in interventions for persons with dementia (Aguirre et al., 2013; Frederiksen et al., 2014; Hoffmann et al., 2016; Spector et al., 2003; Yu and Swartwood, 2012). Results from this study correspond to previous studies showing possible cumulative effects of other kinds of multicomponent non-pharmacological interventions for people with early-stage dementia (Chalfont et al., 2020; Junge et al., 2020).

Receiving a diagnosis of dementia causes considerable distress for people with dementia as well as their families (Bergh et al., 2011; Feast et al., 2016; Frank et al., 2006; Selbæk et al., 2013). Similarly, distancing from existing relationships, lack of initiative and social isolation are common consequences of living with a dementia disease (Atri, 2019; Sørensen et al., 2008b). These themes were regularly cited by participants and caregivers who, at the onset of the diagnosis, had struggled – or still struggle – with such emotions. Another theme often cited by participants and caregivers was the benefit of meeting and sharing with peers. This observation is also in line with other studies, for example, Sørensen et al. 2008a, where being in a group is highlighted as an important factor for supporting and motivating people with early-stage dementia to engage in activities outside the home, strengthening their self-esteem and helping them to find new ways of managing everyday life. This perspective also agrees in line with the increasing attention to promote social health among people with dementia (Vernooij-Dassen et al., 2019). The high prevalence of emotional and social trauma among people with early-stage dementia triggers the call for structured interventions offering them meaningful content in everyday life and social interaction with peers. Our qualitative results indicate that the combination of physical exercise, CST, counselling and psychoeducation constitute a supportive intervention which can promote physical, mental and social health and support coping and self-management of people with early-stage dementia. Further studies are needed to explore the full potential and to provide solid evidence of the effectiveness of such multicomponent interventions, including whether a different combination of the components solely carry the observed benefits.

Moreover, little is known about possible long-term effects on health and well-being of people with early-stage dementia after attending psychosocial interventions. A 3-year follow-up on the Danish Alzheimer Intervention Study (DAISY), involving counselling, education and support, revealed no long-term effect on cognitive function, depressive symptoms and quality of life for people with mild Alzheimer’s disease and their caregivers (Phung et al., 2013). When providing wide-ranging and expensive interventions for home-dwelling people with dementia, it is vital to consider how potential benefits can be maintained in order to keep promoting health and preventing risks of relapse into old habits such as lack of initiative and social isolation. A randomised controlled study assessed how weekly maintenance of CST after an initial CST programme could benefit people with dementia and found significant improvements for activities of daily living performance after 3 months and self-rated quality of life after 6 months (Orrell et al., 2014). Long-term maintenance of one or more components embedded in this multicomponent psychosocial intervention may offer more sustained benefits to the multi-faceted needs of people with early-stage dementia and caregivers, and this perspective should also be explored in future studies.

Strengths and limitations

This study benefits from a mixed-methods design to shed light on the potential benefits of offering a multicomponent psychosocial intervention to people with early-stage dementia. Also, the intervention programme was composed of well-proven and effective components such as physical exercise, CST, psychoeducation and counselling to meet the needs of people with dementia and their caregivers. In addition, the intervention was developed by the municipality and implemented by experienced therapists, which is likely to make it easier for other Danish municipalities to implement a similar multicomponent psychosocial intervention for people with early-stage dementia.

When interpreting the results of this study, there are some limitations to account for. The recruitment of participants to the qualitative part was skewed, leaving almost only men included. An overrepresentation of men might have introduced a distortion in our qualitative findings, for example, highlighting physical exercise as the most beneficial component in the intervention. According to staff members, women were generally more satisfied and excited about CST compared to men.

The pilot study was non-experimental without a control group, so definitive conclusions about the potential benefits should be made with caution as they may not be directly attributed to the intervention. Post-intervention measures did not show any significant changes in physical and cognitive functioning or quality of life. The three measurement methods used to assess physical abilities have been validated and widely used in clinical and health-related research among elderly adults (Marques et al., 2018; Tyson and Connell, 2009; van Loo et al., 2004). However, viewed in hindsight, outcome measures could have been more carefully selected to mirror the outcomes experienced by participants, for example, more sensitive measures of physical performance, as seen in Sobol et al. (2016), where the use of a 6-min cycle test measuring maximal oxygen uptake and test of exercise self-efficacy are combined with similar tests used in the present study. Moreover, psychosocial outcome measures, for example, well-being and social engagement as used by Clarke et al. (2020), could possibly capture the psychosocial benefits of the intervention programme. This pilot study served as a valuable illumination of the importance of using such outcome measures in future studies within this field.

Conclusion

This pilot study provides information about acceptability and potential impact of a combined intervention aimed at people with early-stage dementia. Our results show that combining physical exercise, CST, psychoeducation and counselling is acceptable to participants and their caregivers. Qualitative findings have demonstrated that the intervention constitutes a beneficial activity for people with early-stage dementia since it provides structure and meaningful content in their everyday lives and gives rise to interacting with peers. Moreover, experiencing improvements in physical shape and support from professionals and peers were essential to the participants. Yet, the enhanced benefits were not supported by the quantitative analyses, since they did not detect any significant improvements in physical and cognitive functioning or quality of life. Results from this study underline the moral and ethical obligation to provide sustainable non-pharmacological interventions to maintain and promote the well-being and capacity of people with dementia and their caregivers.

Footnotes

Acknowledgements

We would like to thank all participants in the study for sharing their experiences and thoughts with us. In addition, we acknowledge the staff members at Center for Dementia at the Municipality of Copenhagen.

Declaration of conflicting interest

The author(s) declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclose receipt of the following financial support for the research, authorship, and/or publication of this article: This study was funded by the Municipality of Copenhagen.

ORCID iDs

Sofie Smedegaard Skov

Laila Øksnebjerg

Sigurd Mork Ronbol Lauridsen

Sofie Smedegaard Skov is a PhD student at the National Institute of Public Health, University of Southern Denmark. Her research revolves around mental health with a primary focus on dementia and the ethical dilemmas that arise among people living with the disease, their families and formal caregivers. With an emphasis on participatory methods, the aim of her research is to develop, implement and evaluate practice-related interventions to enhance ethical action competence, as well as promote autonomy and retain dignity among people with dementia.

Maj Britt Dahl Nielsen is senior researcher at the National Institute of Public Health, University of Southern Denmark. Her research focuses on mental health, in particularly on the relation between the psychosocial working environment and well-being. Emphasising participatory methods, the aim of her research is to develop and evaluate interventions to prevent mental health problems and to foster positive and supportive relations at work.

Rikke Fredenslund Krølner is head of Centre for Intervention Research, at University of Southern Denmark. Her research aims at developing, implementing and evaluating public health interventions to provide a scientific foundation for disease prevention and health promotion in local settings. She combines qualitative and quantitative methods to evaluate the implementation and effectiveness of interventions.

Laila Øksnebjerg is MsC in psychology, specialist in clinical neuropsychology and PhD She is also accredited International trainer in cognitive stimulation therapy. She works as a researcher at Danish Dementia Research Centre and Copenhagen Memory Clinic, Rigshospitalet, University of Copenhagen. As a researcher she has a special focus on post-diagnostic interventions and support for people with dementia and their caregivers, for example, self-management, assistive technology, cognitive stimulation therapy and PPI/involvement of people with dementia and their supporters in services and research. She has been PI on research programmes at Danish Dementia Research Centre and was co-lead on the JPND supported working group Dementia Outcome Measures: charting new territory. She is member of Interdem, a pan-European network of researchers collaborating on psychosocial interventions in dementia, where she is member of taskforces for positive health and assistive technology. She also is founder of the Danish Research Network on Psychosocial interventions in Dementia (DaneDem).

Sigurd Lauridsen is head of the research group on mental health and senior advisor at the National Institute of Public Health, University of Southern Denmark. His research focus is on mental health and ethics in dementia care and more broadly in care of people with a chronic illness. He is especially interested in investigating how to deal with ethical dilemmas that emerge when people with dementia gradually lose autonomy.

References

Aguirre

Woods

R. T.

Spector

Orrell

(2013). Cognitive stimulation for dementia: a systematic review of the evidence of effectiveness from randomised controlled trials. Ageing Research Reviews, 12(1), 253-262.

Ask

Langballe

E. M.

Holmen

Selbæk

Saltvedt

Tambs

(2014). Mental health and wellbeing in spouses of persons with dementia: the Nord-Trøndelag health study. BMC Public Health, 14, 413. doi:10.1186/1471-2458-14-413.

Atri

(2019). The Alzheimer's disease clinical spectrum. Medical Clinics of North America, 103(2), 263-293.

Barlow

Wright

Sheasby

Turner

Hainsworth

(2002). Self-management approaches for people with chronic conditions: a review. Patient Education and Counseling, 48(2), 177-187. https://doi.org/10.1016/S0738-3991(02)00032-0.

Bergh

Engedal

Røen

Selbæk

(2011). The course of neuropsychiatric symptoms in patients with dementia in Norwegian nursing homes. International Psychogeriatrics, 23(8), 1231-1239. doi:10.1017/S1041610211001177.

Blankevoort

C. G.

van Heuvelen

M. J. G.

Scherder

E. J. A.

(2013). Reliability of six physical performance tests in older people with dementia. Physical Therapy, 93(1), 69-78. doi:10.2522/ptj.20110164.

Brataas

Bjugan

Wille

Hellzen

(2010). Experiences of day care and collaboration among people with mild dementia. Journal of Clinical Nursing, 19(19–20), 2839-2848. https://doi.org/10.1111/j.1365-2702.2010.03270.x.

Braun

Clarke

(2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3(2), 77-101. doi:10.1191/1478088706qp063oa.

Chalfont

Milligan

Simpson

(2020). A mixed methods systematic review of multimodal non-pharmacological interventions to improve cognition for people with dementia. Dementia, 19(4), 1086-1130. doi:10.1177/1471301218795289.

10.

Chao

I. C. I.

Nicpon

Roduta Roberts

(2020). Effect of cognitive stimulation therapy on quality of life: A critical review. Physical & Occupational Therapy In Geriatrics, 38, 203-229. doi:10.1080/02703181.2020.1716915.

11.

Clarke

Woods

Moniz-Cook

Mountain

Øksnebjerg

Chattat

Diaz

Gove

Vernooij-Dassen

Wolverson

(2020). Measuring the well-being of people with dementia: A conceptual scoping review. Health and Quality of Life Outcomes, 18(1), 249. doi:10.1186/s12955-020-01440-x.

12.

Dewing

(2007). Participatory research. Dementia, 6(1), 11-25. doi:10.1177/1471301207075625.

13.

Feast

Orrell

Charlesworth

Melunsky

Poland

Moniz-Cook

(2016). Behavioural and psychological symptoms in dementia and the challenges for family carers: Systematic review. British Journal of Psychiatry, 208(5), 429-434. doi:10.1192/bjp.bp.114.153684.

14.

Folstein

M. F.

Folstein

S. E.

McHugh

P. R.

(1975). “Mini-mental state”. Journal of Psychiatric Research, 12(3), 189-198. doi:10.1016/0022-3956(75)90026-6.

15.

Frank

Lloyd

Flynn

J. A.

Kleinman

Matza

L. S.

Margolis

M. K.

Bowman

Bullock

(2006). Impact of cognitive impairment on mild dementia patients and mild cognitive impairment patients and their informants. International Psychogeriatrics, 18(1), 151-162.

16.

Frederiksen

K. S.

Sobol

Beyer

Hasselbalch

Wald mar

(2014). Moderate-to-high intensity aerobic exercise in patients with mild to moderate Alzheimer's disease: a pilot study. International Journal of Geriatric Psychiatry, 29(12), 1242-1248. doi:10.1002/gps.4096.

17.

Gibbons

McCurry

Teri

(1999). Quality of life in Alzheimer’s disease: Patient and caregiver reports. Journal of Mental Health and Aging, 5, 21-32.

18.

Henskens

Nauta

I. M.

van Eekeren

M. C. A.

Scherder

E. J. A.

(2018). Effects of physical activity in nursing home residents with dementia: A randomized controlled trial. Dementia and Geriatric Cognitive Disorders, 46(1–2), 60-80. doi:10.1159/000491818.

19.

Hiyoshi-Taniguchi

Becker

C. B.

Kinoshita

(2018). What behavioral and psychological symptoms of dementia affect caregiver burnout? Clinical Gerontologist, 41(3), 249-254.

20.

Hoffmann

Sobol

N. A.

Frederiksen

K. S.

Beyer

Vogel

Vestergaard

Brændgaard

Gottrup

Lolk

Wermuth

Jacobsen

Laugesen

L. P.

Gergelyffy

R. G.

Høgh

Bjerregaard

Andersen

B. B.

Siersma

Johannsen

Cotman

C. W.

Waldemar

Hasselbalch

S. G.

(2015). Moderate-to-high intensity physical exercise in patients with alzheimer's disease: A randomized controlled trial. Journal of Alzheimer's Disease, 50(2), 443-453. doi:10.3233/jad-150817.

21.

Huang

Zhou

Wan

Chang

(2020). Path analysis from physical activity to quality of life among dementia patients: A dual‐path mediating model. Journal of Advanced Nursing, 76(2), 546-554. doi:10.1111/jan.14260.

22.

Huis in het Veld

J. G.

Verkaik

van Meijel

Francke

A. L.

van Meijel

Francke

A. L.

(2020). A systematic meta-review of self-management support for people with dementia. Dementia, 19(2), 253-269. doi:10.1177/1471301218772894.

23.

Joling

K. J.

van Hout

H. P. J.

Schellevis

F. G.

van der Horst

H. E.

Scheltens

Knol

D. L.

van Marwijk

H. W. J.

(2010). Incidence of depression and anxiety in the spouses of patients with dementia: A naturalistic cohort study of recorded morbidity with a 6-year follow-up. The American Journal of Geriatric Psychiatry, 18(2), 146-153. doi:10.1097/JGP.0b013e3181bf9f0f.

24.

Jones

C. J.

Rikli

R. E.

Beam

W. C.

(1999). A 30-s chair-stand test as a measure of lower body strength in community-residing older adults. Research Quarterly for Exercise and Sport, 70(2), 113-119. doi:10.1080/02701367.1999.10608028.

25.

Junge

Knudsen

H. K.

Kristensen

H. K.

(2020). The effect of long-term, group-based physical, cognitive and social activities on physical performance in elderly, community-dwelling people with mild to moderate dementia. Dementia, 19(6), 1829-1843. doi:10.1177/1471301218806376.

26.

Karssemeijer

E. G. A.

Aaronson

J. A.

Bossers

W. J.

Smits

Olde Rikkert

M. G. M.

Kessels

R. P. C.

(2017). Positive effects of combined cognitive and physical exercise training on cognitive function in older adults with mild cognitive impairment or dementia: A meta-analysis. Ageing Research Reviews, 40, 75-83. doi:10.1016/j.arr.2017.09.003.

27.

Lee

H. S.

Park

S. W.

Park

Y. J.

(2016). Effects of physical activity programs on the improvement of dementia symptom: A meta-analysis. BioMed research international, 2016, 1-7. doi: 10.1155/2016/2920146.

28.

Lobbia

Carbone

Faggian

Gardini

Piras

Spector

Borella

(2019). The efficacy of cognitive stimulation therapy (CST) for people with mild-to-moderate dementia. European Psychologist, 24(3), 257-277. doi:10.1027/1016-9040/a000342.

29.

Marques

Pires

Farias

Alvarinhas

Garcia

Marques

(2018). Validation of a method to determine the reaction time in the 30-s chair stand test in elderly people.

30.

Martin

Turner

Wallace

L. M.

Stanley

Jesuthasan

Bradbury

(2015). Qualitative evaluation of a self-management intervention for people in the early stage of dementia. Dementia, 14(4), 418-435. doi:10.1177/1471301213498387.

31.

McKhann

G. M.

Knopman

D. S.

Chertkow

Hyman

B. T.

Jack

C. R.

Jr. Kawas

C. H.

Klunk

W. E.

Koroshetz

W. J.

Manly

J. J.

Mayeux

Mohs

R. C.

Morris

J. C.

Rossor

M. N.

Scheltens

Carrillo

M. C.

Thies

Weintraub

Phelps

C. H.

(2011). The diagnosis of dementia due to Alzheimer’s disease: Recommendations from the national institute on aging-Alzheimer's association workgroups on diagnostic guidelines for Alzheimer’s disease. Alzheimer's & Dementia, 7(3), 263-269. doi:10.1016/j.jalz.2011.03.005.

32.

Montero-Odasso

Casas

Hansen

K. T.

Bilski

Gutmanis

Wells

J. L.

Borrie

M. J.

(2009). Quantitative gait analysis under dual-task in older people with mild cognitive impairment: a reliability study. Journal of neuroengineering and rehabilitation, 6, 35. doi:10.1186/1743-0003-6-35.

33.

Mountain

G. A.

(2006). Self-management for people with early dementia. Dementia, 5(3), 429-446. doi: 10.1177/1471301206067117.

34.

Mountain

G. A.

Craig

C. L.

(2012). What should be in a self-management programme for people with early dementia?. Aging & Mental Health, 16(5), 576-583. doi:10.1080/13607863.2011.651430.

35.

Nowell

L. S.

Norris

J. M.

White

D. E.

Moules

N. J.

(2017). Thematic analysis. International Journal of Qualitative Methods, 16(1), 160940691773384. doi:10.1177/1609406917733847.

36.

Nuzum

Stickel

Corona

Zeller

Melrose

R. J.

Wilkins

S. S.

(2020). Potential benefits of physical activity in MCI and dementia. Behavioural neurology, 2020, 1-10. doi:10.1155/2020/7807856.

37.

Øksnebjerg

Woods

Waldemar

(2019). Designing the ReACT App to support self-management of people with dementia: An iterative user-involving process. Gerontology, 65(6), 673-685. doi:10.1159/000500445.

38.

Orrell

Aguirre

Spector

Hoare

Woods

R. T.

Streater

Donovan

Hoe

Knapp

Whitaker

Russell

(2014). Maintenance cognitive stimulation therapy for dementia: single-blind, multicentre, pragmatic randomised controlled trial. British Journal of Psychiatry, 204(6), 454-461. doi:10.1192/bjp.bp.113.137414.

39.

Phung

Waldorff

Buss

Eckermann

Keiding

Rishøj

Siersma

Sørensen

Søgaard

Sørensen

Vogel

Waldemar

(2013). A three-year follow-up on the efficacy of psychosocial interventions for patients with mild dementia and their caregivers: The multicentre, rater-blinded, randomised Danish Alzheimer Intervention Study (DAISY). BMJ open, 3(11), e003584. doi:10.1136/bmjopen-2013-003584.

40.

Potter

Ellard

Rees

Thorogood

(2011). A systematic review of the effects of physical activity on physical functioning, quality of life and depression in older people with dementia. International Journal of Geriatric Psychiatry, 26(10), 1000-1011.

41.

Quinn

Toms

Anderson

Clare

(2016a). A review of self-management interventions for people with dementia and mild cognitive impairment. Journal of Applied Gerontology, 35(11), 1154-1188. doi:10.1177/0733464814566852.

42.

Quinn

Toms

Jones

Brand

Edwards

R. T.

Sanders

Clare

(2016b). A pilot randomized controlled trial of a self-management group intervention for people with early-stage dementia (The SMART study). International Psychogeriatrics, 28(5), 787-800. https://dx-doi-org.web.bisu.edu.cn/10.1017/S1041610215002094.

43.

Selbæk

Engedal

Bergh

(2013). The prevalence and course of neuropsychiatric symptoms in nursing home patients with dementia: a systematic review. Journal of the American Medical Directors Association, 14(3), 161-169. doi:10.1016/j.jamda.2012.09.027.

44.

Smith

S. C.

Murray

Banerjee

Foley

Cook

J. C.

Lamping

D. L.

Prince

Harwood

R. H.

Levin

Mann

(2005). What constitutes health-related quality of life in dementia? Development of a conceptual framework for people with dementia and their carers. International Journal of Geriatric Psychiatry, 20(9), 889-895.

45.

Sobol

N. A.

Hoffmann

Frederiksen

K. S.

Vogel

Vestergaard

Braendgaard

Gottrup

Lolk

Wermuth

Jakobsen

Laugesen

Gergelyffy

Høgh

Bjerregaard

Siersma

Andersen

B. B.

Johannsen

Waldemar

Hasselbalch

S. G.

Beyer

(2016). Effect of aerobic exercise on physical performance in patients with Alzheimer's disease. Alzheimer's & Dementia, 12(12), 1207-1215.

46.

Sørensen

L. V.

Waldorff

F. B.

Waldemar

(2008a). Early counselling and support for patients with mild Alzheimer's disease and their caregivers: A qualitative study on outcome. Aging & Mental Health, 12(4), 444-450. doi:10.1080/13607860802224342.

47.

Sørensen

L. V.

Waldorff

F. B.

Waldemar

(2008b). Social participation in home-living patients with mild Alzheimer’s disease. Archives of Gerontology and Geriatrics, 47(3), 291-301. doi:10.1016/j.archger.2007.08.011.

48.

Spector

Thorgrimsen

Woods

Royan

Davies

Butterworth

Orrell

(2003). Efficacy of an evidence-based cognitive stimulation therapy programme for people with dementia. British Journal of Psychiatry, 183, 248-254.

49.

Telenius

E. W.

Engedal

Bergland

(2015). Effect of a high-intensity exercise program on physical function and mental health in nursing home residents with dementia: An assessor blinded randomized controlled trial. PloS one, 10, e0126102. doi:10.1371/journal.pone.0126102.

50.

Telenius

E. W.

Eriksen

Rokstad

A. M. M.

(2020). I need to be who I am: a qualitative interview study exploring the needs of people with dementia in Norway. BMJ Open, 10(8), e035886. doi:10.1136/bmjopen-2019-035886.

51.

Toms

G. R.

Quinn

Anderson

D. E.

Clare

(2015). Help yourself. Qualitative Health Research, 25(1), 87-98. doi:10.1177/1049732314549604.

52.

Tyson

Connell

(2009). The psychometric properties and clinical utility of measures of walking and mobility in neurological conditions: a systematic review. Clinical Rehabilitation, 23(11), 1018-1033. doi:10.1177/0269215509339004.

53.

van Loo

M. A.

Moseley

A. M.

Bosman

J. M.

de Bie

R. A.

Hassett

(2004). Test-re-test reliability of walking speed, step length and step width measurement after traumatic brain injury: a pilot study. Brain Injury, 18(10), 1041-1048. doi:10.1080/02699050410001672314.

54.

Vernooij-Dassen

Moniz-Cook

Verhey

Chattat

Woods

Meiland

Franco

Holmerova

Orrell

de Vugt

(2019). Bridging the divide between biomedical and psychosocial approaches in dementia research: the 2019 INTERDEM manifesto. Aging & Mental Health, 25, 206-212. doi:10.1080/13607863.2019.1693968.

55.

von Kutzleben

Schmid

Halek

Holle

Bartholomeyczik

(2012). Community-dwelling persons with dementia: what do they need? What do they demand? What do they do? A systematic review on the subjective experiences of persons with dementia. Aging & Mental Health, 16(3), 378-390. doi:10.1080/13607863.2011.614594.

56.

Woods

(2021). Re-purposing CORDIAL? Toward an effective treatment for depression in dementia. International Psychogeriatrics, 33(3), 195-197. doi:10.1017/S1041610220001209.

57.

Woods

Aguirre

Spector

A. E.

Orrell

(2012). Cognitive stimulation to improve cognitive functioning in people with dementia. Cochrane Database of Systematic Reviews, 15(2), CD005562. doi:10.1002/14651858.CD005562.pub2.

58.

World Health Organization (2020). Dementia - key facts: WHO. Retrieved from:https://www.who.int/news-room/fact-sheets/detail/dementia.

59.

World Medical Association (2013). World medical association declaration of helsinki. Jama, 310(20), 2191-2194. doi:10.1001/jama.2013.281053.

60.

Swartwood

R. M.

(2012). Feasibility and perception of the impact from aerobic exercise in older adults with alzheimer's disease. American Journal of Alzheimer's Disease and Other Dementias, 27(6), 397-405. doi:10.1177/1533317512453492.