How does reading help people with neurological diseases
How reading rewires your brain for higher intelligence and empathy
Fitness headlines promise staggering physical results: a firmer butt, ripped abs, bulging biceps. Nutritional breakthroughs are similar clickbait, with attention-grabbing, if often inauthentic — what, really, is a “superfood?” — means of achieving better health. Strangely, one topic usually escaping discussion has been shown, time and again, to make us healthier, smarter, and more empathic animals: reading.
Reading, of course, requires patience, diligence, and determination. Scanning headlines and retweeting quips is not going to make much cognitive difference. If anything, such sweet nothings are dangerous, the literary equivalent of sugar addiction. Information gathering in under 140 characters is lazy. The benefits of contemplation through narrative offer another story.
The benefits are plenty, which is especially important in a distracted, smartphone age in which one-quarter of American children don’t learn to read. This not only endangers them socially and intellectually, but cognitively handicaps them for life. One 2009 study of 72 children ages eight to ten discovered that reading creates new white matter in the brain, which improves system-wide communication.
White matter carries information between regions of grey matter, where any information is processed. Not only does reading increase white matter, it helps information be processed more efficiently.
Reading in one language has enormous benefits. Add a foreign language and not only do communication skills improve — you can talk to more people in wider circles — but the regions of your brain involved in spatial navigation and learning new information increase in size. Learning a new language also improves your overall memory.
In one of the most fascinating aspects of neuroscience, language affects regions of your brain involving actions you’re reading about. For example, when you read “soap” and “lavender,” the parts of your brain implicated in scent are activated. Those regions remain silent when you read “chair.” What if I wrote “leather chair?” Your sensory cortex just fired.
Continuing from the opening paragraph, let’s discuss squats in your quest for a firmer butt. Picture the biomechanics required for a squat. Your motor cortex has been activated. Athletes have long envisioned their movements — Serena Williams’s serve; Conor McGregor’s kicks; Usain Bolt’s bursts of speed — to achieve better proficiency while actually moving. That’s because their brains are practicing. That is, they’re practicing through visualization techniques.
In one respect novels go beyond simulating reality to give readers an experience unavailable off the page: the opportunity to enter fully into other people’s thoughts and feelings.
This has profound implications for how we interact with others. When encountering a 13-year-old boy misbehaving, you most likely won’t think, “Well, David Mitchell wrote about such a situation, and so I should behave like this,” but you might have integrated some of the lessons about young boys figuring life out and display a more nuanced understanding in how you react.
Perhaps you’ll even reconsider trolling someone online regarding their political opinion, remembering that no matter how crass and inhumane a sentiment appears on screen, an actual human is sitting behind the keyboard pecking out their thoughts. I’m not arguing against engaging, but for the love of anything closely resembling humanity, argue intelligently.
Because reading does in fact make us more intelligent. Research shows that reading not only helps with fluid intelligence, but with reading comprehension and emotional intelligence as well. You make smarter decisions about yourself and those around you.
All of these benefits require actually reading, which leads to the formation of a philosophy rather than the regurgitation of an agenda, so prevalent in reposts and online trolling. Recognizing the intentions of another human also plays a role in constructing an ideology. Novels are especially well-suited for this task. A 2011 study published in the Annual Review of Psychology found overlap in brain regions used to comprehend stories and networks dedicated to interactions with others.
Novels consume time and attention. While the benefits are worthwhile, even shorter bursts of prose exhibit profound neurological effects. Poetry elicits strong emotional responses in readers and, as one study shows, listeners. Heart rates, facial expressions, and “movement of their skin and arm hairs” were measured while participants listened to poetry. Forty percent ended up displaying visible goose bumps, as they would while listening to music or watching movies. As for their craniums:
Their neurological responses, however, seemed to be unique to poetry: Scans taken during the study showed that listening to the poems activated parts of participants’ brains that, as other studies have shown, are not activated when listening to music or watching films.
These responses mostly occurred near the conclusion of a stanza and especially near the end of the poem. This fits in well with our inherent need for narrative: in the absence of a conclusion our brain automatically creates one, which, of course, leads to plenty of heartbreak and suffering when our speculations prove to be false. Instead we should turn to more poetry:
There is something fundamental to the poetic form that implies, creates, and instills pleasure.
Whether an Amiri Baraka verse or a Margaret Atwood trilogy, attention matters. Research at Stanford showed a neurological difference between reading for pleasure and focused reading, as if for a test. Blood flows to different neural areas depending on how reading is conducted. The researchers hope this might offer clues for advancing cognitive training methods.
I have vivid memories of my relationship with reading: trying to write my first book (Scary Monster Stories) at age five; creating a mock newspaper after the Bernard Goetz subway shooting when I was nine, my mother scolding me for “thinking about such things”; sitting in the basement of my home in the Jersey suburbs one weekend morning, determined to read the entirety of Charlie and the Chocolate Factory, which I did.
Reading is like any skill. You have to practice it, regularly and constantly. While I never finished (or really much started) Scary Monster Stories, I have written nine books and read thousands more along the way. Though it’s hard to tell if reading has made me smarter or a better person, I like to imagine that it has.
What I do know is that life would seem a bit less meaningful if we didn’t share stories with one another. While many mediums for transmitting narratives across space and time exist, I’ve found none as pleasurable as cracking open a new book and getting lost in a story. Something profound is always discovered along the way.
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The role of reading on the health and well-being of people with neurological conditions: a systematic review
Introduction
Long-term neurological conditions affect nearly 1 billion people worldwide (World Health Organisation, 2006) and 8 million people in England alone (Neurological Alliance, 2012). Neurological conditions arise from damage to the brain, spinal cord or nerves, as a result of illness or injury (Neurological Alliance, 2012) and commonly cause physical, cognitive, behavioural or communication impairments (Connell & Tyson, 2012; Turner-Stokes et al., 2007). There are many different types of neurological conditions with some being most prevalent in the young; however, the risk of developing neurological conditions, such as stroke (Asplund et al., 2009) and dementia (Lobo et al., 2000) increases with age. The role the arts have to play in our health is now more readily recognised within healthcare (Eakin, 2003) and is supported by an ever-expanding evidence base (Baumann, Peck, Collins, & Eades, 2013). Research into the health benefits of singular arts interventions or mixed arts programmes for people with neurological conditions such as stroke and dementia has identified a range of positive benefits (Baumann et al., 2013; Gotell, Brown, & Ekman, 2009). The therapeutic benefit provided by reading literature was first recognised by the ancient Greeks and Romans who realised that text could be used as a therapeutic tool (McCulliss, 2012). Reading has been considered as a way to maintain general mental well-being since the 1930s (Turner, 2008) and as a treatment for mental health conditions since the 1800s (McCulliss, 2012). There has been a significant uptake of the use of literature in mental healthcare in recent years with multiple ‘books on prescription’ schemes being implemented across the UK since 2002, where general practitioners (GPs) ‘prescribe’ books in addition to or instead of medication (Furness & Casselden, 2012). The role of reading in enhancing the health and wellbeing of older people, those with learning disabilities and those in long-term care settings has also begun to be researched. For older people (especially those in longterm care facilities), reading aloud in a group has been reported to enhance socialisation and provide a valuable link to the world outside of the immediate care setting (Bond & Miller, 1987). The use of literature as a therapeutic tool for people with learning disabilities has only recently been considered, with the outcomes for this group of people including the development and understanding of emotional responses and a gaining of confidence (Cocking & Astill, 2004). Given the acknowledged benefits of reading to general mental health, mental health conditions and more recently, for older people in long-term care and those with learning disabilities, it is possible that reading may also have positive effects on the health and wellbeing of people with neurological conditions. The principal features include the reading aloud of English literature, predominantly ‘classic’ fictional texts such as Silas Marner by George Eliot or poetry such as Crossing the Bar by Alfred Lord Tennyson, in a group session, interspersed with any discussion that is stimulated by participants’ responses to the text. The text is read aloud by the facilitator or any member of the group that wishes to, which ensures that any text, no matter how complex, can be accessible to everyone and does not exclude those who have difficulties with literacy (Davis, 2009). TRO’s model of shared reading is distinct from other reading therapies in that it emphasises the importance of reading ‘classic’ literature, moving away from the idea of prescriptive ‘self-help books’. TRO’s founder Jane Davis explains that reading ‘classic’ poetry and prose is important as ‘the more difficult, the more rich, the less immediately relevant a text the more therapeutic it might be. If the connection with a book comes as a surprise, an active emotional discovery, there may be a more dynamically creative result’ (Davis, 2009, p. 174). She highlights that reading a fictional text enables the reader to have a response to and relationship with the text that is personal to them in comparison to reading an instructive text that has limited scope for engagement. To date little research has been carried out on the effect of group reading interventions with people with neurological conditions (Robinson, 2008). The aim of this review therefore was to establish the role of this type of intervention and/or its components (reading aloud, shared reading in a group, individual or ‘lone’ reading) on improving the health and well-being of those with neurological conditions, and to identify the strength of the current evidence and any gaps in the literature in order to inform future research. Methods Search strategy The search incorporated a number of strategies: a systematic search of electronic databases, internet searching, ‘snowballing’ technique from references of relevant studies and consultation with clinicians and academics in the field. Nine electronic databases (AMED — Allied and Complementary Medicine Database, BNI — British Nursing Index, Cochrane Library, CINAHL PLUS — Cumulative Index to Nursing and Allied Health Literature, EMBASE, ERIC — Education Resources Information Centre, MEDLINE, PsycINFO, Web of Knowledge) were searched from the inception of each database to May 2012 (Week 3) for relevant published literature. Databases were selected to cover an extensive range of health, education and social science disciplines. The search strategy combined indexing terms (for those databases that use MeSH terms) and free text words. The search strategies did not include any date or methodological filters that would limit results to a specific study design.
Inclusion criteria
Studies investigating the effect of lone reading, reading aloud or shared reading in a group on the health and wellbeing of adult or paediatric patients with any neurological condition, in any clinical, community or long-term care setting were included in the review. Studies reporting any clinical outcome measure or subjective outcomes, whether identified through qualitative or quantitative data collection methods and only those reported in English were included.
Exclusion criteria
Studies which included adult or paediatric participants with developmental or learning disabilities or those with a purely mental health diagnosis were excluded. Studies reporting reading interventions for ‘normal’ development of language or numeracy skills, functional magnetic resonance imaging studies using reading to identify impairments or speech and language therapy interventions tailored for individual patients were also excluded. Studies identified by the search strategy were assessed for inclusion in two stages. First, all relevant titles and abstracts identified via electronic searching were screened by one reviewer (J. Latchem) to identify potentially relevant studies for inclusion in the review. Second, full text copies of these potentially relevant studies were obtained and assessed for inclusion using the inclusion/exclusion criteria. The inclusion of each article at this stage was considered and discussed by the two reviewers (J. Latchem and J. Greenhalgh). Disagreements were resolved through discussion. Quality assessment Two reviewers (J. Latchem and J. Greenhalgh) independently assessed the methodological quality of each included study. As studies with differing or multiple methodologies were included in the review, separate quality checklists were required. A bespoke quality checklist was devised for use with the quantitative studies (see Table 1 for checklist items). The items included in the checklist were based on guidance published by recognised experts in the field (Centre for Reviews and Dissemination, 2008; Crombie, 2004). For the qualitative studies, a modified quality checklist based closely upon the nine key questions defined by Popay, Rogers, and Williams (1998) was used (see Table 2 for checklist items). Four mixed-method studies were included in the review and therefore the quantitative and qualitative components were each assessed using the relevant checklist. Discrepancies between quality grading were resolved through discussion.
Data synthesis
The methods, designs and reading interventions included in the quantitative studies were heterogeneous and therefore it was inappropriate to combine their results in a meta-analysis. The data from the qualitative studies were combined using meta-synthesis using thematic synthesis, an approach developed by Thomas and Harden (2008). Thematic synthesis involves the organisation and subsequent thematic analysis of the findings from multiple qualitative studies. Here the process detailed by Thomas and Harden (2008) was followed but in short, anything labelled ‘results’ in the qualitative studies (including researcher thematic analysis, direct quotations and case study reflections) was inputted into the data management software program QSR NVivo9 (QSR International Pty Ltd, Doncaster, Victoria, Australia), and analysed thematically, subject to a process of free line coding, the construction of initial descriptive themes and the final development of analytical themes ready for presentation and discussion. Results were presented in the form of ‘key themes’.
Results
A total of 5622 non-duplicated records were identified by the electronic search strategy and a further 18 articles were identified through snowballing, consultation with experts and Internet searching. All were screened for inclusion and 70 were identified as potentially suitable. The full text was obtained for these articles and the inclusion/exclusion criteria applied. Finally nine publications (seven peer-reviewed articles and two non peer-reviewed research reports) reporting 12 studies in total were included in the review. This included five quantitative studies, three qualitative studies and four mixed-method studies reported in one publication (Billington, Carroll, Davis, Healey, & Kinderman, 2012a). (Please note that five different studies were reported in the Billington et al.’s (2012a) publication but only four met the inclusion criteria for this review.) Results for the quantitative and qualitative components of the mixed-method studies are reported separately. The review process is presented in Figure 1. Methodological quality The quality of the quantitative studies was variable, each with differing strengths and weaknesses. Quality assessments of all included studies are presented in Tables 1 and 2. No randomised controlled trials (RCTs) were identified. Six of the studies were quasi-experimental trials. One study used a control group (Agresti, Corrigan, & Gribble, 1989); in the remaining studies participants acted as their own controls (Billington et al., 2012a; Clair, 1996). Two studies were uncontrolled (Cohen-Mansfield, Marx, Dakheel-Ali, & Regier, 2010; Skrajner & Camp, 2007) and one was a single-subject study (Gardiner, Furois, Tansley, & Morgan, 2000). Five of the seven included qualitative studies were considered to be of good methodological quality (Billington et al., 2012a; Higgins, McKevitt, & Wolfe, 2005). One study (Robinson, 2008) was a short report and much detail of the study and results were missing, which prevented detailed assessment of its overall quality (Table 2). Due to the variability of study design and methodological quality, the quality assessment was of limited use. The process did however lead to the identification of methodological issues for discussion and has given rise to methodological recommendations for future research in this area. Study characteristics and findings Quantitative studies Table 3 describes the key characteristics of the quantitative studies included in this review. The quantitative studies investigated the effect of shared reading in groups, in pairs, lone reading silently or reading aloud. The studies included a total of 266 participants (see Table 4 for participant characteristics). Eight of the nine quantitative studies investigated the effect of a reading intervention on behaviour (e.g. agitation) (Billington et al., 2012a; Clair, 1996; Cohen-Mansfield et al., 2010; Gardiner et al., 2000; Skrajner & Camp, 2007). One study (Agresti et al., 1989) presented short stories to participants in three different modes (story read to the participant, participant read the story silently, participant read the story aloud) and measured the effect the different delivery modes had on recall. In the eight studies investigating the impact of reading on behaviour, a positive impact on the behaviour of interest was found. Three studies reported that reading had a statistically significant positive effect by increasing alert responses (Clair, 1996), reducing agitation (CohenMansfield et al., 2010) and increasing levels of engagement (Skrajner & Camp, 2007). Billington et al. (2012a) (Care Home Group 2) found positive effects for the reduction in the severity of agitation, disinhibition and irritability but these were not statistically significant. The remaining Billington et al. (2012a) studies (Hospital Group A, Day Centre and Care Home 1 and 3) and Gardiner et al. (2000) reported positive effects of shared reading groups in reducing the severity of multiple symptoms caused by dementia, including agitation, anxiety and disinhibition; however, it was not possible to carry out a statistical analysis to determine whether these results were statistically significant due to missing data or small sample sizes. In the Billington et al. (2012a), Hospital Group A and Gardiner et al. (2000) studies, the positive effects measured were found to last up to a week in one case (Gardiner et al., 2000) and several weeks in another (Billington et al., 2012a). As neither of these studies were RCTs, however, the suggestion that reading interventions could have a lasting positive impact on symptoms caused by neurological conditions should be viewed with much caution. Three studies (Clair, 1996; Cohen-Mansfield et al., 2010; Gardiner et al., 2000) investigated reading interventions along with other interventions on the behaviour of people with neurological conditions. Two studies (Clair, 1996; Gardiner et al., 2000) showed that reading in pairs was as effective as music interventions at producing positive effects on behaviour and in the other study (CohenMansfield et al., 2010) the reading intervention was better than practical tasks or one-to-one interaction at reducing agitation and as effective as a music intervention. A number of methodological problems were identified. Investigating the effects of multiple interventions on the same population within a single study may create a cumulative effect and mask the actual effect of a single intervention. Of the three studies (Clair, 1996; CohenMansfield et al., 2010; Gardiner et al., 2000) investigating the effects of more than one intervention or stimulus on the same population, two studies (Clair, 1996; CohenMansfield et al., 2010) delivered multiple interventions in short bursts, one following another, with only brief nonintervention periods in between. Neither of these studies addressed the potential of a cumulative effect nor documented any justifications for the intervention and nonintervention timings they used. In the Gardiner et al. (2000) study, which investigated the impact of two interventions on the disruptive behaviour of two participants, interventions were delivered to participants on different weeks with a gap of a week in between the completion of one intervention period and the beginning of the next. Unlike all of the other studies, Agresti et al. (1989) did not find a positive result, with no statistically significant differences observed in recall between the different modes of delivery. The authors of this study noted, however, that this result could be due to a number of limitations to their study including the variation in reading levels of participants. Qualitative studies Table 5 describes the key characteristics of the included qualitative studies. The qualitative studies included a total of 126 people (see Table 6 for participant characteristics) and reported qualitative findings thematically. The four mixed-method studies (Billington et al., 2012a) were presented in a single research report, with the qualitative results already having been analysed, synthesised and presented thematically. Therefore, the presentation of the results from these studies will be referred to as one here, as data cannot be separated in order to determine whether each theme was apparent in each study. Through data synthesis seven key themes emerged: engagement and attentiveness, social contact, symptomatic impact, sensitive topics, self-expression, personhood, identity and individuality, and enjoyment. Five of the seven key themes identified were evident in all of the qualitative studies, the theme of ‘Personhood, identity and individuality’ was evident in three out of the four studies and the theme ‘Enjoyment’ evident in two of the studies. Themes from qualitative studies Engagement and attention Across all of the studies it was highlighted how the shared reading groups engaged and motivated participants and held their attention as well as providing welcome stimulation. For people with neurological conditions, the shortness of poetry ‘held people’s attention, as they found that they could master the “entire” work without too much mental effort and could remember words, phrases or passages if they were unable to read and relied on listening’ (Robinson, 2008, p. 7). Social contact The experience of reading together, particularly its social impact, was noted across all qualitative studies. Whereas some of these experiences were consistent across the data-set, it is important to note that there were differences in study settings; for example, one study was based on an acute hospital ward and another in a long-term care home. The different effects the group situation had on individuals was also recognised within studies. However, three key areas were reported consistently — the importance of context, interaction and fellowship. The provision of a ‘real’ situation in which to share experiences was observed and valued, and the reading groups also provided participants (especially those who had neurological conditions other than dementia such as stroke) with an opportunity to discuss topics other than their condition (Robinson, 2008). The reading groups facilitated social relationships and fellowship between participants. A noticeable increase in the level of interaction between participants was recognised by staff and discussed specifically within those studies that were ward based, where the reading groups provided an opportunity for people to get to know other patients on the ward, breaking down social and psychological barriers and making the ward a more personal and friendly environment for patients (Higgins et al., 2005). Symptomatic impact All of the qualitative studies provided evidence of the impact of the intervention on clinical symptoms of neurological conditions, with the impact upon memory being the most frequently mentioned. The reading groups were said to ‘spark memories’ (Billington et al., 2012a), and the act of reading poetry in particular was found to stimulate childhood memories in many participants. Alongside the importance of memory, the groups also provided an opportunity for participants to be ‘present’, in the moment. Several project workers not only reflected on the importance of reminiscing, but also commented on the value of participants using their imaginations to create experiences that were in other temporal domains — the present or the future. These project workers also noted the importance of selecting literature that could facilitate and enable participants to focus on present experiences as well as reminiscing about the past. This was considered as being particularly poignant for people with dementia who are often not orientated to time or place and become distressed by this. Sensitive topics All studies reported how the sharing of poems and stories and the social context of the group, by offering fellowship and support, provided a space in which participants felt comfortable discussing sensitive topics and sharing their thoughts and feelings. Many personal experiences and emotions were discussed within the groups including war experiences, loneliness and the need for social contact. The reading groups were even described by participants and healthcare professionals as being ‘emotionally therapeutic’ and ‘cathartic’, addressing participants’ spiritual and emotional/psychological needs. Self-expression and sharing The context of the groups provided participants with the opportunity to express themselves. Three studies reported that reading groups had resulted in positive responses from participants who were not normally known to be particularly communicative or describe how the groups aided those with speech difficulties. One case study presented within the work of Billington et al. (2012a) described a young man who had difficulties communicating and had not spoken at all throughout several groups until he was asked to read. The project worker reported: The poem is five stanzas in length and is quite challenging to read in terms of its rich metaphorical language. When I invited Matthew to read it, he paused for several moments and then answered, ‘Yeah, alright then.’ He read the poem word-perfect. He also read it at a speed which was at much more of a pace with normal conversation: he was fluent and focused…The words on the page were providing him with a voice once again that could be shared, and moreover, with a voice that he wanted to share. (Billington et al., 2012a, p. 11) In the Higgins et al. (2005, p. 1394) study, a nurse who had witnessed the reading groups was impressed by the effects of the intervention and noted how well the group facilitators communicated with dysphasic patients. As a result the nurse ‘began reading to patients herself as an evening activity. She explained that it was often difficult to build a rapport with non-communicative patients and that reading was an extra resource to draw on’. Personhood, identity and individuality The reading groups were considered by participants to create a personal and sensitive setting, which was in contrast to the depersonalisation felt by many in the hospital setting. Through discussion of the texts, the reading groups provided not only a social context for people to share their own experiences with one another, but also as importantly ‘allowed some patients to reconnect with elements of their identity and self unaffected by stroke’ (Higgins et al., 2005, p. 1394). Through drawing on their own past experiences for discussion or reflection, participants could also establish their ‘identity as people with lives, as well as patients with neurological conditions’ (Robinson, 2008, p. 6). Enjoyment Two studies reported how much enjoyment participants experienced when taking part in the reading groups. This was identified by the researchers, staff and participants themselves: ‘At the end of the session I came back to Matthew and asked him if he had enjoyed the session. He said, “Yeah. It was elevating”’ (Billington et al., 2012a, p. 11). Discussion Main findings Due to the variety of reading-based interventions and methodological approaches taken within the included studies, a single or all-encompassing conclusion here is neither possible nor satisfactory. The impact and effect of lone reading, reading aloud and shared reading in a group on the health and well-being of people with neurological conditions is currently an under-researched area. The studies assessed and reported here included people with dementia, post-stroke and brain injury but this literature is limited. Although a number of different types of reading interventions have been researched and reviewed here, research in this area has to date most predominantly focused on the impacts of shared reading rather than lone reading interventions. There is however an even larger dearth of evidence on the effect of reading interventions for people with other neurological conditions such as Parkinson’s disease and multiple sclerosis and for paediatric patients with neurological conditions. However, research detailed in this review, although limited, is encouraging. A number of individual studies reported statistically significant results of positive effects; for example, the reduction of agitation, increase in levels of engagement and number of alert responses in people with dementia. However, these results should be considered with caution due to the methodological issues highlighted earlier. Studies in this review not only provide evidence of the impact of reading in the moment, but also suggest the presence of a lasting effect, of up to a week in one case (Gardiner et al., 2000) and several weeks in another (Billington et al., 2012a). Clinicians working with people with neurological conditions know all too well the difficulties, the repetition and the hard work required in order to create lasting positive change in the symptoms caused by neurological conditions. Such evidence claiming the potential of ‘carryover’ comes from only a small number of studies and is to be considered with extreme caution. Nonetheless, the results are encouraging and further research would be useful to investigate the long-term benefits of reading therapies. A more focused conclusion from the qualitative results can be made due to the consistency of results and subsequent synthesis. The evidence from the qualitative studies consistently demonstrated that shared reading groups engaged and motivated, provided an appropriate context for the facilitation of social interaction, connection and fellowship, evoked memories, provided a platform for self-expression and the sharing of feelings, and helped to re-establish personhood and identity; the groups, therefore, contributed meaningfully to the well-being of the participants with neurological conditions. The context provided through shared reading is important because appropriate context and meaning is necessary in order to positively influence neuroplastic changes within the nervous system following injury or disease (Cramer et al., 2011; Dimyan & Cohen, 2011). For those with neurological conditions, their family and friends, and for the clinicians and carers working with them, symptoms such as agitation and memory loss, communication difficulties and loss of personhood and identity are all too often a lived experience that cannot simply be managed or restored by medication. The evidence presented here demonstrating not only a range of positive effects during the delivery of shared reading, but also the potential of a lasting effect should prompt further research in this area. In light of the potential benefits of reading interventions identified here we hope that this review will be of interest to nursing and therapy staff working with people with dementia or stroke in hospital, rehabilitation settings or long-term care facilities, activities co-ordinators working in long-term neurological care settings who have the daily task of providing group activities and to relatives of people with neurological conditions. Challenges, strengths and limitations This review presented a number of challenges primarily due to the breadth of the question set. Careful framing and setting of inclusion/exclusion criteria was required in order to capture the potential impacts of all components that make up the GiR model of shared reading. Due to the methodological variation of included studies, quality assessment and synthesis of multiple study designs and mixed-method studies were required. The utilisation of mixed-method study designs, where both quantitative and qualitative data are collected, is an evolving area of research design and practice. Recognition of the need and ability to handle mixed methods and multiple data types is especially relevant for interventions of an arts-based nature in a context where the measurement of outcomes in health and well-being are multi-dimensional and this review offers an example of how to manage this in a systematic review. Meta-analysis is seen as ‘gold standard’ evaluation methodology but it is only possible if RCTs have been conducted on the topic and that they measure the same, or very similar outcomes and that multiple studies have been conducted. In the case of arts interventions and the example given by this review, synthesis of data in a meta-analysis is simply not possible or appropriate. Whereas systematic literature reviews in the main focus on assessing the effectiveness of an intervention, in reviews with multi-method and/or mixed-method studies, a lack of RCTs, and experimental-based designs, it may be more useful to adopt a ‘realistic synthesis’ approach (Pawson, 2002, 2006; Wong, Greenhalgh, Westhorp, & Pawson, 2012) — synthesising evidence to build theories about how and why an intervention may or may not be working, the likely mechanisms for how the intervention works and for whom. Further methodological work and reviews such as this one are needed to provide ideas, options and examples of how best to review and synthesise mixed- and multimethodological studies. Recommendations for future research Further empirical research is required to investigate and assess the evidence for the effect of reading interventions such as the GiR model of shared reading and/or its components on the health and well-being of people with neurological conditions. Further qualitative research is required to capture the important subjectively experienced effects of the intervention and to provide an in-depth and rich understanding and a theoretical basis on which to inform and aid the construction of further quantitative research design. The research within this review points towards a potential that group reading interventions could reduce agitation in people with dementia, for example. Further quantitative research to investigate this could be used to confirm or refute this early finding. No RCTs that investigate the effect of reading in people with neurological conditions have been found. Trials with this level of rigour however are needed within this area of research. Researchers should consider the role that cluster randomised trials or appropriately constructed controlled before–after study designs might play in providing a more robust evidence base, which will also be powerful in the context of the on-going dominance of the persuasive power of numbers in Western culture and the hierarchy of evidence-based paradigms. Although we separate our considerations here into qualitative and quantitative designs, the recognition of the place of mixed-method study design is growing and is well placed to investigate the impact of shared reading. We have identified a number of issues related to the research design of the quantitative studies in this review such as short observational time periods of intervention effect. The observation and measurement of the implementation and effect of reading interventions over much longer periods of time is required in order to fully ascertain the depth and length of any effects. We have highlighted studies that investigated multiple interventions within the same study in rapid succession but did not demonstrate any consideration of how each intervention may impact on the effect of the other or the overall outcome. Appropriate consideration and careful study design is needed in instances where multiple interventions or stimuli are to be investigated within a single study.
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Current understanding of Alzheimer’s disease diagnosis and treatment
Abstract
Alzheimer’s disease is the most common cause of dementia worldwide, with the prevalence continuing to grow in part because of the aging world population. This neurodegenerative disease process is characterized classically by two hallmark pathologies: β-amyloid plaque deposition and neurofibrillary tangles of hyperphosphorylated tau. Diagnosis is based upon clinical presentation fulfilling several criteria as well as fluid and imaging biomarkers. Treatment is currently targeted toward symptomatic therapy, although trials are underway that aim to reduce the production and overall burden of pathology within the brain. Here, we discuss recent advances in our understanding of the clinical evaluation and treatment of Alzheimer’s disease, with updates regarding clinical trials still in progress.
Background
Dementia is a clinical syndrome characterized by progressive decline in two or more cognitive domains, including memory, language, executive and visuospatial function, personality, and behavior, which causes loss of abilities to perform instrumental and/or basic activities of daily living. Alzheimer’s disease (AD) is by far the most common cause of dementia and accounts for up to 80% of all dementia diagnoses 1. Although the overall death rate in the United States from stroke and cardiovascular disease is decreasing, the proportion of deaths related to AD is going up, increasing by 89% between 2000 and 2014 2. Direct and indirect costs for healthcare related to AD are estimated at nearly $500 billion annually 3. The definitive diagnosis of AD requires post-mortem evaluation of brain tissue, though cerebrospinal fluid (CSF) and positron emission tomography (PET) biomarkers combined with several relatively new clinical criteria can aid diagnosis in living patients 4. Current treatments available include cholinesterase inhibitors for patients with any stage of AD dementia and memantine for people with moderate-to-severe AD dementia. These medications have been shown to enhance the quality of life for both patient and caregiver when prescribed at the appropriate time during the course of illness; however, they do not change the course of illness or the rate of decline 5.
Clinical research is advancing toward more definitive treatment of the hallmark pathology in AD with the expectation that these therapies will attenuate the progressive cognitive decline associated with this illness ( Figure 1). This review will attempt to summarize the accepted evaluation methods and describe current and future therapies for patients with suspected AD.
Evaluation
Building upon the original 1984 diagnostic criteria, the National Institute on Aging–Alzheimer’s Association (NIA–AA) revised the clinical criteria for the diagnosis of mild cognitive impairment (MCI) and the different stages of dementia due to AD in 2011 6– 8. The use of supportive biomarker evidence (imaging, serum, and CSF) of AD pathology were included to aid in the delineation of AD from other forms of dementia as well as in the diagnosis of MCI due to AD. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) re-classified delirium, dementia, amnestic and other geriatric cognitive disorders into the more encompassing neurocognitive disorders 9. This change was made to better discriminate between different neurodegenerative diseases, such as AD, dementia with Lewy bodies, and frontotemporal dementia, as well as to include both major neurocognitive disorder (equivalent to dementia) and mild neurocognitive disorder (equivalent to MCI) 4. Finally, the newer criteria allow for the use of current and future biomarkers in the diagnosis of degenerative brain disease.
The development of non-invasive diagnostic imaging recently resulted in a test which increases the diagnostic accuracy in AD 10. After injection of a radiolabeled tracer agent, patients undergo a specialized PET scan that detects the deposition of amyloid-β (Aβ) peptides into plaques in the living brain. In 2012, clinicians were able to accurately diagnose the disease (later autopsy proven) using this method with up to 96% sensitivity and 100% specificity. Over the next year, this same test demonstrated similar results in patients with milder disease 11. Nearly a decade after researchers at the University of Pittsburgh created the first tracer, the US Food and Drug Administration approved the use of florbetapir for the detection of AD pathology. Now, the list of amyloid-specific PET ligands includes florbetaben and flutemetamol in addition to florbetapir, all of which have a similar profile 12, 13. However, the use of amyloid PET imaging in practice is still limited owing to its cost for most patients, as it is not covered by most insurance carriers. Currently, the majority of patients who undergo amyloid PET imaging do so as part of participation in clinical trials.
A more-invasive but less-costly evaluation involves examination of CSF for Aβ42, hyperphosphorylated tau peptide (p-tau), and total tau protein content 14. This method has slightly less diagnostic accuracy (85–90%), carries the risks and inconveniences involved with a lumbar puncture procedure, and often takes weeks to obtain results because of the dearth of laboratory facilities which perform the fluid analysis. However, a head-to-head comparison showed no difference in diagnostic accuracy between CSF Aβ42:p-tau ratio and amyloid PET imaging biomarkers, suggesting that the best test for individual patients depends upon availability, cost, and patient/provider preference 15. Less-invasive serum assays designed to detect the quantity of circulating proteins implicated in AD are currently in development and show promise. In 2017, one test discriminated among normal cognition, MCI, and dementia due to AD in a small number of patients with sensitivities and specificities of 84% and 88%, respectively 16. Another blood test that shows promise is the serum microRNA profile screen that demonstrated validity and reproducibility in smaller trials 17. With validation by future larger-scale studies, the hope is that a simple blood test may aid in the diagnosis of AD 18.
Current treatment
At present, only two classes of pharmacologic therapy are available for patients with AD. The cholinesterase inhibitors donepezil, rivastigmine, and galantamine are recommended therapy for patients with mild, moderate, or severe AD dementia as well as Parkinson’s disease dementia 19. Memantine, which has activity as both a non-competitive N-methyl-D-aspartate receptor antagonist and a dopamine agonist, is approved for use in patients with moderate-to-severe AD (mini-mental state examination [MMSE] <15) who show difficulty with attention and alertness 20. For patients who choose alternative therapy, the nutraceutical huperzine A has shown benefit in both memory function and activities of daily living 21. However, while huperzine A is a government-approved medication outside of the US, it is not regulated by the US Food and Drug Administration and may be subject to fluctuations in potency and purity. Vitamin D deficiency was also identified as an independent risk factor for the development of dementia of any cause, and supplementation is recommended for patients in whom deficiency is diagnosed 22. Although many retrospective, observational studies alluded to the role of inflammation in the development of AD by showing a reduced risk of AD with the use of non-steroidal anti-inflammatory drugs, a more-thorough investigation failed to note any significant difference in cognitive performance in patients who took these medications 23. In the past decade, omega-3 fatty acid supplements including fish oil have received much attention owing to their cardiovascular benefits. Two recent randomized, controlled, double-blinded studies showed improvement in thinking and memory in patients with MCI who took fish oil supplements, though these studies were limited by small sample size 24, 25.
Finally, the management of cardiovascular risk factors contributes to overall brain health in both cerebrovascular disease and neurodegenerative disease 26. Recent systematic reviews found that people who adhere to the Mediterranean diet (meals consisting of fresh produce, wholegrains, olive oil, legumes, and seafood while limiting dairy and poultry products and avoiding red meat, sweets, and processed foods) have reduced risk of developing cognitive decline and AD 27, 28. Regular aerobic exercise, long known to prevent metabolic conditions such as diabetes mellitus and coronary artery disease, also shows preservation of function and reduces caregiver burden in patients with AD 29. Not only does physical exercise prevent loss of strength and agility as patients age but it also reduces neuropsychiatric symptoms and the increased care requirements associated with these issues. Recreational physical activity increases cognitive function later in life, with benefit noted regardless of age at the initiation of exercise 30. Less atrophy was observed in the brains of patients with genetic risk factors for AD who exercised regularly compared with those who did not, suggesting that aerobic activity prevents neurodegeneration 31. Although larger controlled studies are still needed to examine the long-term effects of physical activity in patients with biomarker-proven AD pathology, the inherent systemic benefits and lack of health risks should lead all healthcare providers to recommend regular exercise for their patients, regardless of cognitive function.
Future treatment
Research into future treatments of AD involve targeting of the etiologic pathologies: neurofibrillary tangles (composed of p-tau) and senile plaques (Aβ). However, there remains debate as to which abnormality is the best target to slow or halt neurologic decline as well as how soon treatment should be initiated 32, 33. Another approach aims to fortify transcortical networks and enhance inter-neuronal connections in order to enhance cognitive function 34. From previous studies, we learned that early identification of an at-risk population and subsequent treatment in the pre-clinical stage is the approach most likely to slow or halt the progression of AD 35. Clinical trials are underway that aim to recruit asymptomatic patients with a genetic predisposition or biomarkers suggestive of higher risk of developing Alzheimer’s dementia, with results expected early in the next decade. The EU/US/Clinical Trials in AD Task Force in 2016 examined many of these trials in an attempt to identify the most effective measures of patient recruitment and retention, infrastructure development, and patient assessment including biomarkers and objective testing for clinical outcomes 35. Some of the persistent challenges identified include the timeline of recruitment and recruitment failures, difficulty in predicting success based upon prior studies for certain drugs, and the overall costs for such large-scale clinical trials. With a more cooperative effort between researchers, private and public funding, and screening of at-risk populations, a better predictor of successful clinical trials can be created.
Anti-amyloid
According to the amyloid cascade hypothesis, toxic plaques are the earliest manifestation of disease, a statement supported by evidence of Aβ up to 20 years prior to the onset of symptoms 36. Researchers found in 2013 that this abnormal amyloid plaque induces the phosphorylation of tau protein, which then spreads almost infectiously via microtubule transport to neighboring neurons, leading to neuronal death 37. One class of medications developed using this evidence is the monoclonal antibodies (passive immunotherapy). This type of treatment involves injection of an antibody that targets abnormal Aβ and facilitates its removal from the brain. Two such monoclonal antibodies were initially developed in 2014 to remove these plaques from the brains of people with AD 38, 39. Neither medication improved cognitive scores in patients with mild-to-moderate disease (MMSE 16–26), leading researchers to conclude that these medications may show benefit only when administered in the early stages of MCI and mild dementia. However, a new study regarding the effect of this class of medication in patients with few to no symptoms (MMSE 20–26) but a positive amyloid PET imaging result also failed to show a significant difference in cognitive outcomes between the study group and asymptomatic controls 40. Studies involving similar drugs in this class are ongoing, with the goal of improving or preserving cognition in patients with MCI due to AD.
Another approach to decreasing Aβ plaque burden in the brain is the inhibition of the enzymes that produce the Aβ peptide from its precursor, amyloid precursor protein (APP). Currently, multiple drugs are in development which target β-site APP cleaving enzyme 1 (BACE1), which is thought to be essential for the production of Aβ peptides 41. Though previous studies of BACE1 inhibitors failed to yield meaningful results in human subjects, the novel agent verubecestat recently achieved a more than 40-fold reduction in Aβ levels in the brains of rodents and primates, and it has shown a good safety profile in early human trials 42. Currently, another drug is under investigation for its effect on memory and cognitive function in older patients with positive biomarkers or family history of AD, known as the EARLY study.
Researchers showed in 2014 that combination therapy with a monoclonal antibody and a BACE1 inhibitor significantly reduced the amount of Aβ in amyloid-producing mice 43. While there are no current trials underway utilizing this approach in humans, many experts believe that combination therapy employing both approaches to eliminate Aβ will ultimately lead to success in AD treatment 44.
Anti-tau
Since p-tau appears to be the downstream pathology and is likely the direct cause of symptoms in AD, drugs to reduce the burden of this protein are also in development 45. Many different tau vaccines have shown both safety and efficacy in animal models 46, and, in one recent small study, an anti-tau drug demonstrated a good safety profile and even stimulated a positive immune response in human patients 47. Several other early phase trials of drugs which target the tau protein are currently underway, though results are yet to be published 48. Table 1 outlines the treatments and targets currently under investigation.
Neural circuitry
The failure of some targeted therapies toward Aβ in large-scale clinical trials has led to the hypothesis that, although the abnormal protein is implicated at the onset of AD, the progression of clinical symptoms is due to more global neural network dysfunction 49. Gamma oscillation, a high-frequency brainwave rhythm, is associated with inter-neuronal communication in virtually all brain networks 50 and may help to distinguish between true and false memories 51. Recently, researchers at the Massachusetts Institute of Technology found that induction of gamma-frequency oscillations led to reduced Aβ deposition and improved cognitive outcomes in an AD mouse model 52. This was done by using a non-invasive 40 Hz photic stimulator to entrain the desired frequency in the mouse cortex. This method is also currently in early phase trials in humans, utilizing both visual and auditory stimulation.
Summary
As recently as 2010, the diagnosis and management of AD relied upon clinical symptom reporting that fit the pattern of memory dysfunction and loss of functional independence in multiple cognitive domains. With the reclassification system devised by the NIA–AA and DSM-5, the spectrum of AD has grown to include pre-clinical disease and MCI, helping to lay the foundation for early identification of at-risk patients. There are now a few widely available diagnostic studies that augment the clinical evaluation for a more accurate diagnosis of AD pathology, including bodily fluids and imaging studies, with good specificity.
However, the treatment options for AD remain supportive and symptomatic without attenuation of the ultimate prognosis. Medications such as cholinesterase inhibitors and memantine improve memory and alertness, respectively, without changing the life expectancy or overall progression of AD dementia. Lifestyle modifications including diet and exercise remain the only interventions with evidence showing lower AD risk and possible prevention of overall cognitive decline, and these interventions are first-line recommendations for all patients regardless of cognitive function. The pathological features associated with AD, Aβ and p-tau, are the current targets for potential treatments; however, early success in comparative studies and smaller clinical trials are thus far not reproducible in larger-scale administrations. Although limited evidence suggests that earlier identification of AD pathology will lead to better and more-definitive treatment, the results of larger-scale interventions are not yet available for review. Given the rising prevalence and mortality of AD coupled with the growing total healthcare costs, there continues to be a sense of urgency in the medical community to develop effective means for the early diagnosis and successful treatment of this progressive neurodegenerative disease.
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Reading Aloud and Arithmetic Calculation Improve Frontal Function of People With Dementia
RECENTLY, the importance of cognitive rehabilitation for patients with dementia has been argued (1). The aims of cognitive rehabilitation for patients with dementia include optimizing functioning and well-being, minimizing the risk of excess disability, and preventing the development of a malignant social psychology within the patient’s family and social environment (2). Because memory impairment is a common attribute of any dementia subtypes, most of the intervention programs for dementia care focus on memory trainings.
In this study, we propose a new intervention program, the concept of which is derived from the knowledge of both brain science and clinical studies. Memory impairment and cognitive disturbances, such as aphasia, apraxia and agnosia, and disturbance of executive function, are the main cognitive deficits in dementia, and the association cortices, particularly the dorsolateral prefrontal cortex, are involved in these cognitive functions (7,8). The decrease in regional cerebral blood flow (rCBF) in the frontal, parietal, and temporal association cortices is commonly the case for dementia (9–11). Therefore, cognitive impairments in dementia patients may well result from dysfunction in those association cortices.
In human brain-mapping studies, brain areas showing increases in rCBF and metabolism in relation to performance of cognitive tasks have usually been reported (12). Therefore, we can identify specific cognitive tasks which increase rCBF and metabolism of these association cortices, particularly the dorsolateral prefrontal cortex, from those in previous brain-imaging studies. In this study, we hypothesized that activation of the association cortices by cognitive tasks may well improve rCBF and metabolism of these cortices, which lead to improve the function of these cortices.
To choose effective cognitive tasks for activation of the association cortices, we reviewed previous neuroimaging studies published elsewhere and/or those by our laboratory. In this process, we selected brain-activation paradigms that satisfy the following two criteria: a) the paradigms must activate the dorsolateral prefrontal cortex, as well as the parietal and temporal association cortices of the bilateral hemispheres compared with the resting state, and b) the paradigms must be very simple, so that people with senile dementia can follow and perform them. Finally, we identified two tasks: a) reading sentences or words aloud (13–16) and b) performing simple arithmetic operations (17–22), both of which met our above-mentioned criteria.
Therefore, we prepared two tasks in arithmetic and Japanese language, which were systematized basic problems in reading and arithmetic, for the training program. The theoretical flaw of our hypothesis is that it is not clear whether activation of brain networks involved in reading and calculations can improve functions of brain network(s) involved in other cognitive processes. To test our hypothesis and to overcome this problem, we measured the effect of continuous learning by elderly people with dementia on their brain functions and activities of daily living. In this study, we focused mainly on the function of the frontal cortex. The limitation of this study is that we could not determine the role of social, emotional, and cognitive factors in the training effect.
METHODS
Subjects
Sixteen individuals in the experimental group and 16 in the control group were recruited from a nursing home for the elderly, called Eiju-no-Sato, in Fukuoka, Japan. The subjects were randomly assigned to these two groups. Written informed consent was obtained from each individual using forms approved by the Tohoku University and the Declaration of Helsinki (1975). Clinical diagnostic evaluation by neurologists and an X-ray computed tomography examination of the brain were performed on each participant. In this study, none of the participants had abnormalities such as tumors, cerebral bleeding, cerebral infarction, or pathological brain atrophy, on X-ray computed tomography examination. All of the individuals in both groups had a clinical diagnosis of dementia Alzheimer type (DAT) that met the criteria of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV). The participants in the learning group were asked to perform a training program using learning tasks 2–6 days a week at learning centers in Eiju-no-Sato. To estimate the change in the cognitive ability of the participants, Mini-Mental Status Examination (MMSE) (23) and Frontal Assessment Battery at the bedside (FAB) (24) were measured in each participant of each group. In the learning group, the neuropsychological characteristics were measured prior to the start of the training program (baseline) and 6 month after the training program had taken place (follow up). In the control group, the same characteristics were measured at the same time as in the learning group. The baseline clinical and neuropsychological characteristics of the learning and control participants are summarized in Table 1. In addition, ability for verbal communication and independence was estimated in both groups by two individual items of scales for mental state and daily living activities for the elderly, named the NM scale (25). Neither assessment score showed a statistically significant difference between the two groups (independent samples t test). Except for the training program, both groups of participants had the same nursing care programs at the same place.
Learning Tasks
The materials for the training program were two tasks in arithmetic and Japanese language, which were systematized basic problems in reading and arithmetic. We prepared a wide range of materials, which were used for everyday learning for 4-year-old children to fourth grade elementary school students (that is, 10-year-olds). The problems were printed on both sides of A4-size paper. As for the arithmetic problems, the lowest level was counting practice, and the highest level was three-digit division. As for the Japanese language problems, the lowest level was to read and write single syllables, and the highest level was to read aloud fairy tales. Prior to the training program, the appropriate degree of difficulty and workload for each participant were assessed by a diagnostic test, so that he or she could continue to perform the learning tasks with ease.
The participants came to the learning center either on summons by the staff, or on their own initiative every day from Monday to Saturday. They would complete two to five sheets of each task prepared for each individual for that day, and their work would be assessed by the staff. The mistakes were corrected by the participants. If they could not solve a problem by themselves, the staff members stationed between desks provided sufficient advice for them to be able to solve it. The study period ended when the participants completed each of the problems correctly. The daily learning time for the two tasks was approximately 20 minutes.
Statistical Analyses
The neuropsychological characteristics of both groups were compared using an independent sample t test at baseline and at follow-up. A further analysis comparing baseline and follow-up scores separately for the learning and control groups was performed by paired t test. Statistical significance was set at p <.05 for all the comparisons.
RESULTS
Neuropsychological Characteristics
All the participants in the learning group continued the program for more than 6 months. The mean (SD) of the training days was 19.2 (4.6) days per month.
The scores of the neuropsychological characteristics at baseline and follow-up are summarized in Figure 1. In the learning group, the FAB score showed a statistically significant (p <.05) increase after the training had taken place. However, the MMSE score did not show any significant changes. In the control group, the MMSE score showed a statistically significant (p <.05) decrease at follow-up compared with baseline. Nevertheless, the FAB score did not show any significant changes. At follow-up, the MMSE and FAB scores for the learning group were statistically significantly (p <.05) higher than those for the control group. There was no relationship between the magnitude of change in the scores of the neuropsychological characteristics and initial scores on the MMSE or FAB in the learning group.
The scores of the individual items of the FAB at baseline and follow-up are summarized in Table 2. At follow-up, the score for similarities (conceptualization) was significantly (p <.05) higher in the learning group compared with the control group. In the control group, the score for motor series (programming) showed a statistically significant (p <.05) decrease at follow-up compared with baseline. In the learning group, the score for similarities (conceptualization) showed a statistically significant (p <.01) increase at follow-up compared with baseline. There was no relationship between the magnitude of change in the scores of the individual items of the FAB and the number of training sessions that the learning group participants attended.
The scores of the individual items of the NM scale at baseline and follow-up are summarized in Table 3. In the learning group, the score for independence showed a statistically significant (p <.05) increase at follow-up compared with baseline. Although score for verbal communication showed an increase at follow-up compared with baseline, it did not reach a statistically significant level (p =.1). In the control group, the score for verbal communication showed a subthreshold decrease at the p =.1 level at follow-up compared with baseline.
Examples of the Case Patients
Case 1
A 75-year-old man had baseline FAB and MMSE scores of 3 and 13, respectively. After the 6-month training period, his FAB and MMSE scores increased to 10 and 15, respectively. He showed reactivation of his communicative ability during the course of training. Before the start of the training, he could only speak a few words, and remained motionless in the same place, wearing an anxious expression. After the learning period, his number of spoken words increased, his voice became clearer, and he initiated conversation on his own. Moreover, before the learning period he had to be reminded by the staff about bowel movements, but 3 months after the learning period, he was able to go to the toilet by himself.
Case 2
A 77-year-old woman had baseline FAB and MMSE scores of 5 and 7, respectively. She also showed reactivation of her communicative ability during the course of training. Before the learning period she almost did not converse at all. She began to speak simple words and, after 6 months, she could hold a simple conversation, and began to return smiles to the staff in corridors.In particular, right after the start of the program she sometimes refused the learning tasks, but after 6 months she started to come to the learning center by herself. In the early stages she came to the learning center in her pajamas; later, she came dressed in regular daytime clothing. As learning became more natural for her, she began to express thanks for the care given to her, her expression relaxed, and she began to smile in her daily life.
DISCUSSION
In this study, we demonstrated that a training program in reading and arithmetic problems, named a Learning Therapy, was effective in dementia care for the improvement of cognitive functions. All of the experimental participants showed improvement in verbal communications with the nursing staff. In addition, significant improvement was observed in verbal conceptualization with regard to the FAB. It is also important to note that cognitive ability measured by MMSE did not decline during the 6-month learning period.
The term rehabilitation is defined as a process of active changes aimed at enabling people who are disabled by injury or disease to maintain an optimal level of physical, psychological, and social functions (26). Recently, in line with this view, cognitive rehabilitation approaches for people with dementia have been introduced. Because memory impairment is a common attribute of any dementia subtype, most of the intervention programs for dementia care have been focused on memory training (3–6). Learning Therapy has two significant characteristics that distinguish this method from previous methods of cognitive rehabilitation. One is that this method is not an evidence-based method; it relies on the theoretical background of the knowledge of neuroscience research — that is, solving arithmetic problems and reading aloud activate bilateral dorsolateral prefrontal cortex of humans. The second is that it aims to mediate transfer of the different cognitive functions within the dorsolateral prefrontal cortex — that is, from reading aloud and solving arithmetic problem functions toward general cognitive functions such as communication, independence, and conceptualization. Although in the present study, DAT patients showed improvement in the several cognitive functions following daily training in reading aloud and solving arithmetic problems.
It has been widely recognized that one of the significant functional roles of the dorsolateral prefrontal cortex is to carry out executive functions. The executive functions mediated by the frontal cortex involve planning, selection, and ongoing regulation of behavior (27). A number of studies (28,29) reported a deterioration of the executive functions in DAT, and showed that impairment in performance of a variety of tasks in DAT patients are related to executive dysfunctions (30). In Learning Therapy, daily training is focused on reading aloud and solving arithmetic problems. Reading aloud is accomplished by the combination of several cognitive processes, for example, recognition of the visually presented words, conversion to phonological representation from graphic representation of words, analysis of the meaning of words, and control of pronunciation. Solving arithmetic problems is also accomplished by many cognitive processes, for example, recognition of visually presented numbers, performance of arithmetic operations, and control of hand movements. It is obvious that both reading aloud and solving arithmetic problems require executive functions. Neuropsychological studies of children with cognitive disorders indicated that reading disability (31–34) as well as arithmetic disability (35,36) is related to the impairment of executive functions. In the present study, significant improvement was observed in verbal conceptualization with regard to the FAB in the experimental group. The verbal conceptualization test was designed to measure the ability to identify abstract categories (24). Abstract category is impaired in frontal damage (37), is investigated by the Wisconsin Card Sorting Test, which is commonly used and considered as an important indicator of frontal dysfunction (38), and is one of the important aspects of executive function (39). Therefore, in the case of Learning Therapy, one possible explanation for the transfer of cognitive functions is the improvement of executive functions during the course of training.
The other important result of Learning Therapy is improvement in communication between nursing staff and participants. Because immediate feedback of participants’ performance was required during Learning Therapy, this therapy improves face-to-face verbal communication, and the communication behavior of the nursing staff changed during the course of the daily trainings.
It was suggested that, in general, the quality of staff–resident communication is often observed to be less than optimal (40–43). Because nursing home staff perceive themselves as too busy to talk with the residents, they are noted to have low expectations of the residents, leading to low levels of social interaction. The residents themselves perceive the staff as too busy to engage in conversation, and feel that they should not bother them unnecessarily (44–46). Cognitive impairments are correlated with decreased engagement, conflict, and distress in nursing home residents (47,48), and changing the communicative behavior of the nursing staff could have a strong positive impact on the residents (49). Therefore, in the present study, improvement of the cognitive function, particularly communication, of the learners may well have resulted from the increased opportunity for staff–learner communication in daily care. This point is one of the limitations of interpretation of the results of our study. In this study, we were not able to distinguish whether the source of benefits for the experimental group was the cognitive training itself, the interaction with the experimenters working with the experimental group, or the additional attention received by the experimental group from the nursing home staff. Future investigations attempting to determine the role of social, emotional, and cognitive factors in the training effect are necessary.
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Resumen en español:
Recientemente se ha argumentado la importancia de la rehabilitación cognitiva para los pacientes con demencia . Los objetivos de la rehabilitación cognitiva para pacientes con demencia incluyen optimizar el funcionamiento y el bienestar, minimizar el riesgo de discapacidad excesiva y prevenir el desarrollo de una psicología social maligna en el entorno familiar y social del paciente . Debido a que el deterioro de la memoria es un atributo común de cualquier subtipo de demencia, la mayoría de los programas de intervención para el cuidado de la demencia se centran en el entrenamiento de la memoria.
En este estudio, proponemos un nuevo programa de intervención, cuyo concepto se deriva del conocimiento tanto de la ciencia del cerebro como de los estudios clínicos. El deterioro de la memoria y los trastornos cognitivos, como la afasia, la apraxia y la agnosia, y la alteración de la función ejecutiva, son los principales déficits cognitivos en la demencia, y las cortezas de asociación, particularmente la corteza prefrontal dorsolateral, están involucradas en estas funciones cognitivas. La disminución del flujo sanguíneo cerebral regional en las cortezas de asociación frontal, parietal y temporal suele ser el caso de la demencia. Por lo tanto, los deterioros cognitivos en pacientes con demencia bien pueden resultar de una disfunción en esas cortezas de asociación.
Por ello, preparamos dos tareas de aritmética y lengua japonesa, en las que se sistematizaron problemas básicos de lectura y aritmética, para el programa de formación. En este estudio, nos enfocamos principalmente en la función de la corteza frontal.
La Terapia de Aprendizaje tiene dos características significativas que distinguen este método de los métodos anteriores de rehabilitación cognitiva. Una es que este método no es un método basado en evidencia; se basa en el trasfondo teórico del conocimiento de la investigación en neurociencia, es decir, resolver problemas aritméticos y leer en voz alta activa la corteza prefrontal dorsolateral bilateral de los humanos. La segunda es que tiene como objetivo mediar la transferencia de las diferentes funciones cognitivas dentro de la corteza prefrontal dorsolateral, es decir, desde leer en voz alta y resolver problemas aritméticos hasta funciones cognitivas generales como la comunicación, la independencia y la conceptualización. Aunque en el presente estudio, los pacientes con demencia mostraron una mejora en varias funciones cognitivas después del entrenamiento diario en lectura en voz alta y resolución de problemas aritméticos.
En este estudio se demostró que un programa de entrenamiento en problemas de lectura y aritmética, denominado Terapia de Aprendizaje, fue efectivo en el cuidado de la demencia para la mejora de las funciones cognitivas. Todos los participantes experimentales mostraron una mejora en las comunicaciones verbales con el personal de enfermería. Además, se observó una mejora significativa en la conceptualización verbal con respecto a la FAB. También es importante señalar que la capacidad cognitiva medida por MMSE no disminuyó durante el período de aprendizaje de 6 meses.
Resumen en inglés:
Recently, the importance of cognitive rehabilitation for patients with dementia has been argued. The aims of cognitive rehabilitation for patients with dementia include optimizing functioning and well-being, minimizing the risk of excess disability, and preventing the development of a malignant social psychology within the patient’s family and social environment. Because memory impairment is a common attribute of any dementia subtypes, most of the intervention programs for dementia care focus on memory training.
In this study, they propose a new intervention program, the concept of which is derived from the knowledge of both brain science and clinical studies. Memory impairment and cognitive disturbances, such as aphasia, apraxia and agnosia, and disturbance of executive function, are the main cognitive deficits in dementia, and the association cortices, particularly the dorsolateral prefrontal cortex, are involved in these cognitive functions.
They prepared two tasks in arithmetic and Japanese language, which were systematized basic problems in reading and arithmetic, for the training program. The theoretical flaw of our hypothesis is that it is not clear whether activation of brain networks involved in reading and calculations can improve functions of brain network(s) involved in other cognitive processes.
It has been widely recognized that one of the significant functional roles of the dorsolateral prefrontal cortex is to carry out executive functions. The executive functions mediated by the frontal cortex involve planning, selection, and ongoing regulation of behavior. A number of studies reported a deterioration of the executive functions in DAT, and showed that impairment in performance of a variety of tasks in DAT patients are related to executive dysfunctions.
In Learning Therapy, daily training was focused on reading aloud and solving arithmetic problems. Reading aloud is accomplished by the combination of several cognitive processes, for example, recognition of the visually presented words, conversion to phonological representation from graphic representation of words, analysis of the meaning of words, and control of pronunciation. Solving arithmetic problems is also accomplished by many cognitive processes, for example, recognition of visually presented numbers, performance of arithmetic operations, and control of hand movements. Ergo, both reading aloud and solving arithmetic problems require executive functions.
They proved that Learning Therapy was effective in dementia care for the improvement of cognitive functions. All of the experimental participants showed improvement in verbal communications with the nursing staff.
