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Title: Evaluation of a computer-assisted errorless learning-based memory training programme for patients with early dementia
Authors: Lee, Yuet Ying Grace
Degree: Ph.D.
Issue Date: 2014
Abstract: Introduction: Cognitive training can be effective in enhancing the cognitive function of older adults with cognitive impairment by possibly delaying the onset of dementia. The present study aimed to develop a theory-driven, computer-assisted errorless learning-based memory programme (CELP) for patients with early dementia; and to compare the training outcomes of a CELP group, with a therapist-led errorless learning training programme (TELP) and a control group (CG), receiving conventional treatment as usual. The programmes are based on a postulated errorless learning (EL) and enriched environment (EE) training model, and refer to cognitive reserve and neuroplasticity theories on dementia interventions. It was hypothesized that the CELP and TELP would have better treatment effectiveness compared with the CG. Method: A randomized control trial (RCT) with a single-blind research design was adopted. Independent assessors and trainers were responsible for evaluation and training separately. Hong Kong Chinese older subjects with early Alzheimer's Disease (AD) were screened by the cut-off score of 1 using the Chinese version of Clinical Dementia Rating (CDR). The subjects were randomly allocated to a CELP, a TELP and a control group (CG) respectively. Evaluation of subjects before and after intervention and at a three-month follow-up was achieved by primary outcomes: the Chinese Dementia Rating Scale (DRS), the Chinese Mini-Mental State Examination (MMSE), and the Hong Kong List Learning Test (HKLLT). Secondary outcomes included the Chinese version of the Geriatric Depression Scale- Short Form (GDS-SF). Subjects{174} specific performance on prospective memory was evaluated through interviews with the subjects' carers using the Chinese Brief Assessment of Prospective Memory (BAPM-carer). A 15-session, 45-minutes individualized CELP was designed for Chinese AD subjects based on EL training principles, incorporating different memory strategies (such as spaced retrieval, and with an enriched multi-sensory training environment) and using familiar daily life training scenario. The TELP is a training package of similar training content and format, but being delivered by therapists using a colour training manual with standardized instructions. The CELP and TELP were run twice weekly, in less than two months. Subjects in the CG attended a conventional training programme as usual. Pilot study and expert panel review: An expert panel review was done to evaluate the structure, content and computer-human interaction effect of the CELP. A RCT pilot study with 19 subjects was done with the purpose to review the applicability of the CELP. To reinforce the learning of subjects and better encoding of information, the structure of the training programme was further enhanced from 30 minutes training to 45 minutes and added in 3 revision sessions at intervals to consolidate the learning. The errorless memory training programme was finalized as with a structure of a total of 15-session 45 minutes training programme. The result of pilot study was used to support main study sample size estimation. Main study: A total of 115 AD subjects were screened from in-, day- and out-patients units of the psychogeriatric team at a local Kwai Chung Hospital, three dementia day care centres, two elderly day care centres and four elderly homes/ Care and Attention Homes in Hong Kong. Seventy-five subjects were successfully recruited into the CELP (n=30), TELP (n=22) and CG (n=23) and completed the study. Repeated measures ANOVA were used as statistical data analysis. There was no significant difference in the three groups for baseline outcome assessment measures, indicating homogeneity. Subjects showed statistically significant post-test score differences, as compared with pre-test evaluation, in the DRS total score (p=0.001) and the DRS memory subscore (p=0.012) among the three groups, with a better outcome improvement in the CELP and TELP than mild deterioration in the CG. There was a statistical significant difference in the CELP and TELP, when compared with the CG (p=0.001) while there was no statistically significant difference in the CELP and TELP. Also, significant positive changes in the HKLLT immediate recall subscore (p=0.005), the MMSE (p=0.01) and BAPM-carer (p=0.002) were found in the CELP and TELP in post-test assessment but there was not much improvement in the CG. This reflected an improvement in memory process in the subjects of the intervention groups but with a decline in cognitive function at the three-month follow-up while there was a general trend of very mild deterioration in the cognitive score for the CG in the post-test. This difference might be due to a natural cognitive decline of subjects with dementia. In comparison, the CELP group showed better improvement in the scores of the HKLLT immediate recall (in encoding) and the BAPM as reported by carers when compared with the TELP; while the TELP had a better improvement in the MMSE and GDS scores in the post-test evaluation. Both the CELP and TELP showed quite similar improvement in the post-test score of the DRS total.
Thus, Chinese early AD subjects were found to have better improvement in overall cognitive function after attending the EL memory programme while the computer group showed better memory scores as reflected by a more efficient encoding of information in an audio-visual stimulus-enriched environment. The CELP offered an innovative, alternative training programme for older Chinese adults, which was built up with systematic gradation, and rich audio-visual feedback. Subjects were reinforced positively in a supportive, enriched, computer environment during training. This may save therapists valuable time to run individual training programme for indicated early AD persons. For the TELP, therapists were more flexible and gave more individual prompting, guidance and extra support to subjects, based on the needs and capability of the individual subject to enhance accurate association, encoding of new information during the EL training and to overcome the subjects{174} literacy, attention, prospective memory and behavioral problems. Conclusion: This study showed that EL is an effective strategy to enhance the memory function of Chinese early AD patients in Hong Kong. Both the CELP and TELP have shown a positive treatment effect on cognition when compared with the CG. The encoding problem, working memory, executive function and prospective memory function of AD patients were improved after intervention by the CELP and TELP. However, positive treatment effect has a limited carrying over effect over three months and might have a low generalization effect to daily life function with the existing training structure in terms of volume and frequency. The CELP demonstrated better cognitive outcomes than the TELP in post-test and in the DRS total score, DRS memory subscore, HKLLT immediate recall and BAPM score. The TELP showed better cognitive outcomes in the MMSE in post-test and had better sustainability of treatment effect in the MMSE and BAPM in the three-month follow-up. Clinically, AD patients may be advised to have constant cognitive training or home programme to maintain their cognitive function. The EL training programme might be enhanced by increasing the number of overall training session to 20 sessions or more, with an increased training frequency to more than two times per week. Further support on the EL memory training from carers might be further explored. Based on the neuroplastic training theory, in future, an early cognitive assessment and intervention programme for Chinese older adults is highly recommended. A large-scale RCT multi-centre study might be done for older Chinese patients with Mild Cognitive Impairment or early AD, using the CELP (on mobile tablets) to enhance cognitive function. A cognitive health training programme might be launched for adults at the age of around 55-60, as a preventive programme to minimize the risk of developing dementia.
Subjects: Dementia -- Patients -- Care
Hong Kong Polytechnic University -- Dissertations
Pages: 17, 202 leaves : illustrations (some color) ; 30 cm
Appears in Collections:Thesis

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