Aging Clin Exp Res (2013) 25:403409

DOI 10.1007/s40520-013-0062-5

ORIGINAL ARTICLE

Evaluation of the efficacy of a cognitive rehabilitation treatment

on a group of Alzheimers patients with moderate cognitive
impairment: a pilot study
Paolo Salotti Brunetto De Sanctis
Andrea Clementi Mila Fernandez Ferreira
Tania De Silvestris

Received: 21 August 2012 / Accepted: 6 February 2013 / Published online: 13 June 2013
Springer International Publishing Switzerland 2013

Abstract The aim of this study was to evaluate the efficacy of a cognitive rehabilitation intervention performed in
an Alzheimers Day Care Center for 12 months on patients
suffering from Alzheimers-type dementia with moderate
cognitive impairment. In the cognitive rehabilitation
treatment of moderate cognitive impairment, the leading
cognitive stimulation techniques are reality orientation
therapy and cognitive training. While these techniques are
meant to treat different cognitive environments, there is
scarce documentation in literature about their joint use. For
this purpose, the therapy was administered to two groups of
patients: the experimental group was composed of four
subjects and received cognitive rehabilitation (cognitive
training plus reality orientation therapy); the control group
was composed of five subjects and received aspecific
stimulation. To assess subjects responses the Milan
Overall Dementia Assessment and the Mini-Mental State
Examination were used for the cognitive domain, while the
Geriatric Depression Scale was used for the affective
sphere. The results indicated that the subjects submitted to
cognitive rehabilitation obtain statistically significant
results compared to the control group from the 9 months of
treatment, in clinical terms; they maintain their cognitive

P. Salotti
B. De Sanctis
A. Clementi

M. Fernandez Ferreira
T. De Silvestris
General Unit of Psychology, Adult Neuropsychology
Outpatients Department, Belcolle Hospital, AUSL Viterbo,
Viterbo, Italy
P. Salotti (&)
Ospedale Belcolle, str. Sammartinese, 01100 Viterbo, Italy
e-mail: paopall@alice.it

performance, while no significant differences were found

between the two groups as far as the affective domain is
concerned.
Keywords Cognitive rehabilitation
Alzheimers disease

Cognitive training
Introduction
Alzheimers disease (AD) is a degenerative and progressive syndrome affecting the central nervous system, characterized by a gradual progression of deficits in cognitive,
mood and behavioral functions [1]. AD starts with a mild
cognitive impairment characterized by a deficit in the
episodic memory (on-going memory) [2] accompanied by
attention deficits, especially of selective and divided
attention [3] and language deficits with anomia and linguistic uncertainty, still capable of being corrected.
In the affective domain, mild and fluctuating states of
anxiety, apathy and dysphoria appear. The intermediate
phase of the disease implies a moderate cognitive impairment characterized by a more severe disturbance of episodic memory, which is also associated with a deficit of
semantic memory [1]; spatial and temporal disorientation
[4]; difficulty in controlling the automatic attentional processing; reduced problem-solving, abstraction and speech
capabilities [3]. Moreover, in the affective domain,
depression and aggressivity appear; also, incongruous and
inappropriate behaviors occur, involving the possibility for
delusions and hallucinations to arise. The advanced stage
of disease, instead, involves a severe cognitive impairment
that occurs with further deterioration of the autobiographical memory of past events [2], the procedural memory
(habitual actions carried out in daily life) and the attentional functions, consisting of more context-dependent

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responses. The language deficit leads to the disappearance

of spontaneous production and echolalia. Moreover, psychotic symptoms like delusions and hallucinations may
often appear [3]. It is well known that for the time being
there are no possibilities to cure Alzheimers patients.
However, there are various treatment methods available
(both pharmacological and non-pharmacological), that give
different results according to the level of disease severity.
The non-pharmacological techniques, especially those
focusing on the cognitive domain, are receiving growing
accreditation. This is due to different factors, such as the
numerous studies on their effectiveness [5], the limited
effects of drug therapies on cognitive impairment [6, 7] and
studies demonstrating the plasticity of the central nervous
system [8, 9]. The most important methodologies that focus
on the stimulation of cognitive functions are ROT (reality
orientation therapy [1012]) and CT (cognitive training,
[13, 14]). The ROT technique makes use of repetitive
multimodal stimulation (visual, verbal, written) to
strengthen the patients spatial and temporal orientation
and ability, and bring the patients attention toward him/
herself and his/her environment.
Various studies have underlined the effectiveness of this
technique [15], emphasizing improvements in the cognitive
and behavioral domain in Alzheimers disease with mild,
moderate or severe cognitive impairment [16, 17].
Cognitive training (CT, [13]) is instead based on several
exercises proposed with paper and pencil or through the
use of the computer. CT is aimed at stimulating such
cognitive functions as memory, attention, language and
executive functions. This second approach has proved to be
effective in improving the cognition, everyday activities,
behavior and mood of patients with both initial and moderate dementia. Nevertheless, the various methodological
aspects of the various studies carried out up to now are not
entirely exempt from criticism (absence or low quality
RCTs, poorly specified interventions, absence of a theoretical model [5, 13]).
Taking start from this situation, our study proposes a
combination of stimulation methods aimed at addressing
the peculiar problems of patients suffering from moderate
cognitive impairment by means of specific theoretical
models (ROT and CT combined, as ROT mainly improves
space, time and other orientation factors and as the results
obtained so far from CT concern different cognitive functions, so their combined action was chosen to treat both
aspects) and of a given treatment protocol.
This work is aimed at evaluating the effectiveness of nonpharmacological combined cognitive treatment on a group
of patients with Alzheimers dementia at intermediate stage
and moderate cognitive impairment, through a mixed-design
variance model analysis (over a period of 12 months)
involving an experimental group and a control group.

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Aging Clin Exp Res (2013) 25:403409

Method
Subjects
The sample consisted of nine female patients with a mean
age of 80.1 and 4.1 years of education (Table 1). Patients
attended an Alzheimers Day Care Center for more than a
year, all of them were diagnosed with probable Alzheimers dementia according to DSM-IV TR [18] and NINCDS-ADRDA [19] with moderate cognitive impairment
(Global Deterioration Scale = 5; [20]).
The subjects did not show neither sensory or communication disorders nor behavioral symptoms, so they were
judged eligible for the treatment. All subjects received
donepezil therapy (10 mg/day) for several years before the
beginning of this study and throughout its duration.
Interventions
The patients underwent a series of aspecific group stimulations 3 days a week. Four of them, in the last 12 months,
also underwent cognitive stimulation based on a combination of two therapies ROT and CT (experimental
group-EG) three times a week. The remaining five subjects
(control group-CG) continued instead their usual aspecific
stimulation activities. The patients were not treated for
depression or other behavioral symptoms during the entire
course of the study.
In the first part of the rehabilitation session, the therapeutic scheme involved ROT application to stimulate space
and time orientation. The use of schedules, calendars and
clocks was also introduced to facilitate both information
learning and retrieval.
In the next part of the session, cognitive training on
attention, memory and speech was applied.
The rehabilitation sessions were performed individually
with a duration of 1 h per patient. For cognitive training we
used cards, paper and pencils. In general, the rehabilitation
approach was based on stimulation cards of growing
complexity that were given to each patient as his/her

Table 1 Clinical and sociodemographic characteristics of patients at

the baseline
Variable

Control group
mean (SD)
(n = 5)

Experimental group
mean (SD)
(n = 4)

Students t

p value

Age
Education
(years)
MMSE
MODA
GDS

77.80 (6.14)
4 (2.75)

83 (3.24)
4.25 (0.82)

1.35
0.154

0.219
0.882

16.70 (0.74)
65.72 (4.76)
12.6 (1.81)

17.27 (0.38)
65.22 (2.38)
12.50 (1.29)

0.566
0.209
-0.092

0.589
0.840
0.929

Aging Clin Exp Res (2013) 25:403409

response capabilities improved. During each cognitive

training session attention cards were distributed first, then
memory cards and then language cards, focusing particularly on attention and memory functions that required
greater stimulation.
As far as attention is concerned, we used a method
inspired by the Sohlberg and Mateer protocol [21]. The
stimulations were based on barrage exercises where the
targets to be identified ranged from colored geometric
shapes to black and white geometric shapes, to meaningless
shapes.
After that we focused on selective attention, using sustained attention cards and increasing visual and auditory
noise, e.g., by displaying plastic sheets in different color
shades over the cards to distort the pictures and by adding
distracting noises to make it harder for the patients to focus
on the target stimuli. Lastly, we focused on divided
attention through stimulations based on the dual task paradigm (e.g., patients had to perform barrage exercises with
cards and at the same time identify auditory stimuli from
readings or audio recordings). In this case too the degree of
difficulty increased as the quantity (from individual to
multiple) and the type of the stimuli increased.
As far as memory is concerned, the procedure was based
on the use of own methods, i.e., mental strategies devised
or applied by each patient to facilitate the memorizing
process [22].
We therefore developed cards consisting of stimuli
related to words and pictures, where patients had to apply
cognitive techniques aimed at reorganizing their strategic
capabilities and at replacing the abilities they had lost with
others they had maintained. In particular, the techniques
used were spaced retrieval [23], a technique in which
associations are repeatedly recalled at increasingly longer
intervals; errorless learning [24], an intervention based on
verbal elaboration, and vanishing cue, that uses external
cues to build the correct succession of cognitive or procedural operations for expanding rehearsal; repetition
priming [25], which consists of giving the patients information that they cannot remember to have received previously, but that nevertheless turn out to be still existing
and operational at subconscious level, favoring the
patients subsequent and faster learning of similar or related information.
On these theoretical grounds, during the early months of
training we focused on the stimulation of working memory
to improve the retention of new information [26] by means
of lists of words that patients had to learn. The first list
comprised words belonging to the same semantic category
(e.g., parkfountain); the second list comprised words still
related to the same category but in double number that the
patients had to report (e.g., train-railroad, railcar); the third
list comprised words belonging to different semantic

405

categories (e.g., clown-pen). While proceeding, we changed the stimulation (visual channel), using the same format
but with pictures instead of words that the patients had to
learn. Lastly, we stimulated visuo-spatial memory by
means of cards made up of a checkerboard containing
various kinds of pictures. After memorizing their positions,
the patients had to re-enter the pictures in an empty
checkerboard. Here we articulated the degree of difficulty
by gradually increasing the quantity of stimuli to be
memorized, by varying information storage and retrieval
intervals, and also by requesting patients to perform distracting tasks before retrieving the information.
As far as language is concerned, we focused on the
stimulation of output lexicon deficits using various protocols commonly used in the clinical practice [27, 28].
We started by stimulating verbal fluency with oral production exercises, based on a phonological approach
(growing in complexity through the introduction of
restrictions to the words that the patients were supposed to
generate) and, subsequently, on a syllabic approach (the
exercise started with the patients reporting any sort of word,
then only words related to object names, changing both
word quantity and retrieval time to make the exercise
increasingly difficult). Going ahead, we focused again on
verbal fluency stimulation, using stimuli related to semantic
categories with the same scale of difficulty. In the last stage
we focused on verbal comprehension, proposing plain texts
or newspaper articles for the patients to read, and then
asking questions to verify their understanding of the text.
Assessment
Each course of treatment was preceded and followed by a
neuropsychological assessment based on these tests: Milan
Overall Dementia Assessment, MODA [29] and MiniMental State Examination, MMSE [30]. The first one is
composed of three sections: orientation, autonomy and
neuropsychological part, and examines memory, attention,
abstraction capability, language, visual perception, executive functions and agnosia. The score varies between 0 and
100; a score lower than 85.5 indicates an abnormal cognitive status; a score between 85.5 and 89.0 shows a borderline status; finally, a score higher than 89.00 designates
a normal cognitive status.
The MMSE instead is a rapid screening test with correct
scores varying from 0 to 30. These scores can indicate
severe cognitive impairment (010); moderate cognitive
impairment [1120]; mild cognitive impairment [2123]
and normal cognitive status [2430].
The Geriatric Depression Scale, GDS [31] was used to
evaluate the affective domain. This scale presents scores
from 0 to 30, indicating absence of depression (010);
moderate depression [1120] and severe depression [2130].

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Procedure
The experimental procedure was made up of individual
therapy sessions of duration of 60 min conducted by a
psychologist expert in neuropsychology. The therapy sessions were always performed at the same time of day,
3 days a week, at the Alzheimers Day Care Center, for a
period of 12 months. During the entire term of the study,
the treatment was interrupted for 2 weeks every 3 months.
During this period, a neuropsychological assessment was
also performed by another psychologist not involved in the
therapy, to monitor the efficacy of the rehabilitation
process.
Statistical analysis
A mixed-design analysis of variance 2 9 5 (ANOVA) was
used, employing post-hoc analyses with Bonferroni correction. Treatment condition was used as first independent
variable between subjects, expressed on two levels
(experimental and control). The second independent variable within subjects was time, expressed on five levels
(each being a 3-month treatment cycle). The dependent
variable was represented by the Scores obtained from the
three assessment instruments, which detected affective and
cognitive functioning at different time intervals. The first
was the performance score before the beginning of the
treatment, while the remaining four were the performance
scores as obtained at the end of each treatment cycle.
Finally, a trend analysis was also performed for both
groups, reviewing their significance within each group in
the five treatment levels. SPSS software version 15.0 was
used for data analyses.

Fig. 1 Results obtained from the MODA in the experimental group

(EG) and the control group (CG) during the rehabilitation process

Fig. 2 Results obtained from the MMSE in the experimental group

(EG) and the control group (CG) during the rehabilitation process

Results
The demographic and clinical characteristics were not
significantly different between the two groups at baseline
(Table 1). In line with expectations, a first qualitative
analysis of overall results showed that the test scores for
MODA (Fig. 1) and MMSE (Fig. 2) were different and
presented an increasing trend for the experimental group
and a decreasing trend for the control group; the gap was
greater for MODA results than for MMSE ones. Moreover,
relatively to GDS test scores (Fig. 3), an inconstant tendency during the various phases of treatment cycles within
the two groups (EG and CG) was observed.
As to cognitive function, a significant difference
between the group subject to experimental condition and
the control group was detected. This difference was relative
to the independent variable between subjects (Treatment)
(F (1, 7) = 10.482; p = 0.014). This result was analyzed

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Fig. 3 Results obtained from GDS test in the experimental group

(EG) and the control group (CG) during the rehabilitation process

Aging Clin Exp Res (2013) 25:403409

in detail by post hoc comparisons, performed with the

Bonferroni correction (significance level p \ 0.05). It was
noticed that the difference between the two conditions
started to emerge from the third treatment cycle, i.e., after
9 months of treatment. The difference between the two
groups remained significant for the subsequent two cycles
of therapy. In addition, a significant interaction was found
between the Time variable (five treatment cycles) and the
Treatment variable (experimental and control groups)
(F (4, 28) = 17.729; p = 0.000), while the effect of the
Time variable (F (4, 28) = 1.554; p = 0.214) was not
significant. The trend analysis showed for both groups a
significant linear trend, growing in the experimental group
(F (1, 3) = 45.831; p = 0.007) and decreasing in the
control group (F (1, 4) = 23.829; p = 0.008).
The MMSE, similar to the MODA, showed a significant
difference between the experimental group and the control
group. This difference was relative to the Treatment variable (F (1, 7) = 23.604; p = 0.002). A more detailed
analysis of this effect, based on post hoc comparisons
performed with the Bonferroni correction (significance
level of p \ 0.05), confirmed, as described above for the
MODA, that the difference between the two conditions
started to emerge only from the third treatment cycle
onwards, and then remained significant for the subsequent
two cycles of therapy. In addition, a significant interaction
was found between the Time variable (five treatment
cycles) and the Treatment variable (experimental and
control groups) (F (4, 28) = 6.770; p = 0.001); however,
the effect of the Time variable (F (4, 28) = 2.311;
p = 0.083) was not significant. The trend analysis showed
for both groups a significant linear trend, growing in the
experimental group (F (1, 3) = 41.818; p = 0.008) and
descending in the control group (F (1, 4) = 9.000;
p = 0.040).
As to the affective domain, detected with the GDS, no
significant effect was found with respect to the Treatment
variable (F (1, 7) = 0.161; p = 0.700), neither in terms of
interaction between the Time variable and the Treatment
variable (F (4, 28) = 0.192; p = 0.940), nor in terms of
effects of the Time variable (F (4, 28) = 0.439, p = 0.633).
Finally, the trend analysis revealed no significant trends for
both groups (experimental: F (1, 3) = 3.271; p = 0.168;
control F (1, 4) = 0.106; p = 0. 761).

Discussion
The results of statistical analysis from MODA and MMSE
showed uniform and coherent results. The cognitive treatment performed on the experimental group produced,
compared to control subjects, a significant positive change
in the answers to both the tests administered, and the result

407

may be interpreted in clinical terms as a preservation of

cognitive functions. This result is particularly impressive if
considered that the control group was submitted to a specific stimulation for the entire duration of the study which
probably had a positive influence on cognitive and affective levels.
Furthermore, an important aspect that emerged regarded
the time required to achieve such improvement. Results
were seen after at least 9 months of intensive cognitive
treatment carried out three times a week on patients with
Alzheimers dementia and moderate cognitive impairment.
Thereafter, the benefit remained constant from the third
through the fifth cycle. Regards to the affective domain
(GDS), no statistically significant change in mood was
found in the two groups studied. However, both groups
showed a tendency to get high during the entire treatment
program. This trend was slightly more evident in the
experimental group than in the control one [32, 33]. It is
worth noting that both groups were involved for more than
a year in the activities proposed at the Alzheimers Day
Care Center. This fact may partly explain the observed
groups tendency toward a slight improvement.

Conclusions
According to the data reported, this study suggests a
preservation of cognitive performance among subjects with
moderate AD submitted to one-year cognitive rehabilitation at an Alzheimers Day Care Center. The cognitive
function improvement appeared to be statistically significant from the 9 month of therapy, compared to the control
group. However, the affective functions showed a slight
improvement in both groups of patients, more evident in
the experimental than in the control group. It should be
considered that all patients (both in the experimental and in
the control group), before starting the day centre activities,
had received donepezil (10 mg) drug therapy. Considering
that this medication generally produces little or no benefit
on the cognitive function [6, 7], the results reported in this
study may be attributable to the specific cognitive rehabilitation carried out. This outcome seems in line with both
the recent study by Giordano [34] and with NICEE [35]
guidelines, that recommend cognitive stimulation in Alzheimers dementia with moderate cognitive impairment.
Also other studies, such as for instance those carried out
by Requena [36], Talassi [37] and Akanuma [38], among
others, seem to present similar results going in the same
direction, although they use different treatment methods.
The possibility to generalize our results is limited by the
small dimensions of the sample and by the lack of subject
randomization in both experimental conditions, and also by
the activities proposed at the Alzheimers Day Care Center,

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that inevitably influenced the patients cognitive and

affective levels.
Notwithstanding the recognized limits of this study, we
have at least tried to describe the treatment plan implemented and the type of action carried out.
However, following this pilot study, we intend to study a
larger sample on longer therapy intervals, followed by
extended follow-up over time, to gather even more information on cognitive rehabilitation effects and to confirm
the results obtained with this study.
Conflict of interest

None.

15.
16.

17.

18.
19.

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