F. Gaio*, A. Baretter*, M. Dello Buono**, D. De Leo** e I. Maestri***
*Logopedista, I.R.A., Istituto di Riposo per Anziani, Padova, Italia
**Servizio di Psicogeriatria,Università di Padova, Italia
***Logopedista, Italia
Fabiola Gaio, IRA Istituto di Riposo per Anziani, Via Beato Pellegrino 192, 35137 PADOVA (Italie)
Tél : 0498721011 - Fax : 049660407

Definition of rehabilitational methods must be characterized by the following principles:

· theoretical bases

· specific intervention strategies

· assessment instruments

· objectives

· outcome

· costs/benefits

(La riabilitazione cognitiva e cognitivo-comportamentale nel demente. Zanetti & Metitieri, 1998, modificata)

The main limitations in the assessment of the efficacy of rehabilitational interventions with patients with dementia are the following:

· theoretical bases are not sufficiently well-defined

· heterogeneity of subjects

· lack of blind assessments

· unvalidated assessment instruments

· difficulty in reporting negative results

· influence of external psychosocial variables (caregivers, professional workers)

(La riabilitazione cognitiva e cognitivo-comportamentale nel demente. Zanetti & Metitieri, 1998, modificata)

Although the rehabilitation of patients with dementia has always been viewed negatively, more recent studies have demonstrated that positive results can be achieved when those functions that remain relatively unaffected are stimulated, especially in the early and intermediate stages of the disease.

A very well-known cognitive rehabilitation technique is Reality Orientation Therapy (R.O.T.), developed by Folsom in 1958 at the Veterans Administration (Topeka, Kansas) and subsequently applied by Taulbee & Folsom in the 1960s as a specific rehabilitation technique for confused or cognitively impaired subjects.

The aim of R.O.T. is to reorient the subject in relation to himself /herself, his own history and surrounding environment.

Over the years, attempts have been made to ascertain the efficacy of this therapy. The results of a longitudinal, controlled study by Zanetti and colleagues in 1995 suggested that R.O.T. could slow down the decline in cognitive abilities in subjects with mild to moderate impairment, without overt behavioural disorders. The research team of the Psychogeriatric Service of the University of Padua, based on experience with formal R.O.T., proposed applying this technique in a multimedia format, following adequate adaptation. The aim of this project was to assess the application potential of an extensive computerized package to demented subjects in an institutional setting .

The study was conducted at the IRA Elderly Rest Home in Padova, Italy, where the residents are aged 65 years and over. The Rest Home has 500 non-self-sufficient residents who are divided up into seven units coordinated by the geriatricians.

Various services are provided by the Rest Home, including Speech and LanguageTherapy, Physiotherapy, Social Stimulation, and a number of Social Workers are available.

· diagnosis of mild to moderately severe Alzheimer's disease

· a score between 18 and 23 on the Mini Mental State Examination (MMSE - Folstein et al., 1975)

· attention-memory deficits reported at staff meetings by the multidisciplinary team

· absence of severe visual and auditory impairment.

A total of 62 residents were identified, 42 of whom met the established criteria. Twenty five of these residents who met inclusion criteria were placed in the rehabilitation programme and 17 in the control group. The sociodemographic characteristics and other sample variables are summarized in Table 1.

The case group and control group were matched in terms of age, gender, educational level, presence of a hearing loss, length of stay, care, participation in physical therapy activities, social stimulation and illnesses occurring during the study period. There was a significant difference between the two groups with respect to visual impairment: whereas the case group included four visually impaired subjects, none of the residents in the control group were affected by uncorrected visual impairment.

1) Token Test (Spinler & Tognoni, 1987) (theoretical range: 0-36), to assess the ability to discriminate and understand verbal messages in the form of a command;

2) Alzheimer's Disease Assessment Scale (ADAS), to assess mentally impaired elderly persons through tests of mnestic efficiency and cognitive status (Rosen, Mohs & Davis, 1984 - Italian version: Fioravanti).

3) The subscale of the Brief Symptom Inventory (BSI) on subjectively perceived depression, administered to assess the presence of any self-perceived symptoms and whether participation in training had any impact on depression.

This assessment was conducted in two sessions, lasting approximately 45 minutes each, at an interval of three days.

Therapy was administered twice a week over a maximum of 10 sessions, each lasting approximately 30 minutes. Residents were informed that the objective of this treatment was to help recover memory and overcome difficulties in accessing lexical elements (anomia). The elderly person readily recognized these difficulties which, in most cases, were openly observable; this increased motivation for treatment. The exact overall purpose of ROT is in fact far more extensive: the experimental program included in the CD-ROM is composed of 7 exercises geared to stimulating visual and auditory memory, recall ability, recognition and spatial orientation in impaired elderly persons.

• drawer exercise: three objects which are used in daily life are presented (wallet, box and sheet of paper), then hidden in three different drawers. The elderly person must remember exactly where each item has been placed, thereby exercising spatial memory, particularly memory of places.
• face exercise: three persons are introduced, after which the elderly subject must be able to make a name-face association.
• shopping exercise: visual memory and recognition are stimulated by choosing one item out of three objects from the same semantic category.

After correctly performing two of the first level exercises, the person moves on to the second level.

• orientation exercise: this explores spatial orientation by presenting three routes, one at a time. When each itinerary has been presented, the subject is asked to follow the same route once again, by indicating the correct direction to take (right, left, straight on).

After completing Level II in its entirety, the elderly person moves on to Level III.

Level III:

• face exercise: the subject must recall from remote memory the names of the six people introduced
• recall the names of famous people: a few video sequences of four well-known persons are presented. In this case, the auditory component is associated with the visual component.

• the Library exercise. This exercise is divided into five sections: the first part concerns the general setting, along with some film trailers, songs, poems and old television advertisements with which the elderly persons are familiar. This exercise is verbally guided by the therapist rather than the electronic tutor. This exercise is designed to create a relaxing atmosphere, with less structure than the previous exercises. This promotes an exchange of communication and helps the subject recall personal-type events. It has been designed to gradually stimulate the sensory (hearing and sight) and cognitive capacities of the subject, particularly short- and long-term memory and comprehension of the functional elements of a verbal message.

An exercise can only be considered completed when it is correctly performed in two consecutive sessions. For each section of the drawer, face, shopping and orientation exercises, a maximum of 5 trials is allowed to provide the correct response. After five erroneous answers, the operator is trained to suggest the answer, both in order to avoid excessive frustration on the part of the subject and to ascertain, at the time of the next session, whether learning took place with fewer trials.

To ease comprehension of the verbal message and make it more informative and clear, linguistic variations had to be adopted during training.

Therapy lasted approximately two and a half months, due to health and/or organizational problems in the rest home during the study period.

· Quantitative analysis of number of trials needed for each exercise by the 25 residents

· Qualitative analysis of answers, taking into consideration the number of repetitions, which are indices of fixed logical thought processes and an inability to solve problems;

· Statistical analysis of the test results obtained from the 25 test and 17 control subjects.

Statistical analysis was conducted by comparing frequencies, applying the chi square test for contingency tables for categorical variables and by comparing mean scores with Student's t-test for continuous variables.

Table 2 shows the results of comparisons between mean scores achieved on the tests and subtests administered to the subjects at the beginning (T0) and end (T1) of therapy.

In comparing mean scores and standard deviations, a statistically significant improvement emerged for almost all tested areas.

There was also a constant improvement in functions such as temporal orientation, attention, recall and language. In general, the global MMSE score was significantly improved. Lack of statistical significance was obtained only on those subtest scores measuring spatial orientation and short-term memory.

A comparison of the scores obtained on the cognitive subscales of the Alzheimer’s Disease Assessment Scale (ADAS) also showed a statistically significant improvement in immediate and delayed recall and delayed recognition. Conversely, results from naming tests remained virtually unchanged over the training period, while measures of immediate recognition improved, although statistical significance was not reached.

Scores on the Token Test, which examines comprehension of spoken language, showed statistically significant improvement. A qualitative analysis of the type of errors suggested a fall in the number of errors made on the test as a whole, especially on sections which are easier in terms of sentence construction.

In sections involving coordinated sentences, mistakes persisted, although they were considerably reduced, primarily with regard to nouns and adjectives (colour). In the sections containing subordinate sentences and sentences with prepositions, there was a fall in the number of mistakes in the test as a whole, which also mainly involves nouns and adjectives.

Most errors persisted in coordinated sentences with adverbs and conjunctions.

A very important point to bear in mind is that the number of responses provided by the experimental subjects increased, resulting in a reduction of nonresponses. This means that despite being unsure of the right answer or answering incorrectly, elderly persons were prepared to try just the same. This characteristic is worthy of note because it is well-known that elderly people, especially institutionalized ones, tend to withdraw into their own world and to avoid all situations which confront them with their own difficulties.

An analysis of linguistic variations indicated that during the 10 sessions these variations were used differently, depending on the requirements and cognitive characteristics of each individual resident. In general, however, the first variation tended to be the most frequently used (see graph A), being closest to the item originally suggested by the computer. Indeed, the item proved to be the type of linguistic formulation of the question most frequently used during the 10 sessions, particularly the last three.

The original item had to be repeated word for word to those subjects with lower attention capacity ; this can be accounted for by the fact that, as the sessions progressed, detailed explanations were no longer necessary because subjects tended to learn and remember the exercise.

The Depression subscale of the BSI (Derogatis & Melisaratos, 1983) was administered to all subjects, in order to assess the impact of therapy on mood. Treated elderly persons moved from a mean score of 1.55, SD=0.85, to a mean score of 1.30, SD=0.91, t = 2.29, p<0.03.

Although the number of subjects included in this pilot study may seem small, it can be concluded that these data, supported by more specific data related to the progress of the elderly persons in the individual exercises, are definitely in favour of the validity of the instrument, even at this experimental stage.

Various difficulties were encountered during the sessions, due primarily to the need to coordinate organization of the treatment with other educational or social activities (parties, day trips and excursions, ceremonies, etc.) and other forms of rehabilitation (physiotherapy).

· the evaluation tests administered indicated general improvement (see table 3 )

· the residents became much more open to dialogue without building defensive barriers to the operator, who might be the therapist or a nurse from their residential home unit;

· during treatment, some residents also improved in their daily orientation.(for example, they came on their own from their room to the therapy room)

Our brief experience taught us that this type of programme incorporates various positive features which encourage its application to the elderly population:

1. the computer is a complex, new instrument which stimulates curiosity and attention;

2. it is a concrete working tool, with "hands-on" opportunities;

3. the use of photographic material not only provides a faithful representation of reality, but also respects, within the rehabilitative setting, the fact that the elderly person is an adult;

4. it creates a natural, spontaneous linguistic setting in which the elderly person's attention is focused on the exercise rather than on those linguistic aspects which he/she is consequently stimulated to use and which the speech therapist can also use for therapy purposes. Subjects are also encouraged to ask questions whenever they do not understand what is said and requested in each exercise;

5. this programme also operates at various semantic category levels, stimulating recall, recognition and useful naming capacities, which are helpful in the case of anomia.

6. it stimulates auditory and visual attention, both selective and sustained over time, for the various stimuli proposed.

An effort is now already underway to technically improve the ROT programme and to extend the study sample. This programme has been applied to other non-institutional settings, such as the home, with the hope of increasing family members’ involvement.

In view of these results, pessimism towards treatment of people with dementia may also be reconsidered: although dementia cannot be "cured", methods can be sought to slow down cognitive decline and to delay placement in residential care as long as possible.

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