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The non pharmacological treatment of cognitive impairment in older subjects Torna agli editoriali

Anna Giulia Cattaneo, M.D.

The incidence of cognitive impairment and dementia significantly increases with age. The aging process is not merely related to the frequency, instead it differentiates greatly the healthy and the wellness of individuals affected by dementia, as well as the prognostic values and the therapeutics.

The significant amount of efforts spent in the last half century to improve the personal wellness and the social adequacy of younger people affected by different syndromes reducing their psychological and mental performances resulted in many cases in a surprisingly high degree of rehabilitation.

In the case of older individuals, the physiological decrease of a number of abilities influencing the cognitive process negatively affects the expectation. In the elderly, mainly when associated with cognitive impairment, both psychological attitudes (like the learning ability, the interest in doing new experiences, the personal skills to face changes in life) and physical abilities, sensorial or motor, are frequently reduced.

The relative and however important state of poverty is in many cases a disadvantage affecting the frailest people, the older among others. The care givers and the society themselves shows a general indifference to the wellness of people considered no more productive and a heavy social burden, with death in a near future. The attention paid to major dementias, like the Alzheimer disease, seems in many cases that shared by all the nightmares of our society, all the conditions implying the introduction of a frail ring in the social network. This is the reason why the economical factors surroundings the taking care of the elder people are so often underlined even in scientific literature.

From the point of view of the older, this attitude is a font of stress, a risk added to the eventual loss in cognitive skills, which in fact in the elderly rise from a mixed pathology, only in part degenerative and (or) vascular, but in part secondary to depression, loss of interest , and sensory inadequacy.

A recently published study (Dement. Geriatr. Cogn. Disord. 2010, 30: 161-178) summarizes the results of a large multicenter project defined to evaluate and standardize the non pharmacological therapy for the Alzheimer disease. The approach ranges from cognitive training, music and light use, to massage and therapeutic touch, or transcutaneous electric stimulation. The indications vary for the different approaches: some methods are especially aimed to improve mood, other to ameliorate physical skills. Learning new activities improves self-esteem and preserves intellectual abilities and motion, when done in small groups this method has also positive influence on the maintenance of social relationships and affectivity. However, the standardization of the methods applied and their precise timing is required to optimize the results. Every different type of intervention is accurately described in the cited paper, and the original work is clearly cited, to facilitate the reproduction of the treatment in a standardized manner.

This approach could be successfully extended to all types of cognitive impairment, and however it should be considered that its limits are especially evident in the case of the most seriously compromised subjects. The non pharmacological approach, in fact, does seem to be equally effective on all the needs of demented people, and it rarely reaches a potential grade A level of recommendation. In particular, it does not reduce the risk of falls, the mortality rate and the need of psychotropic drugs, does not improve the compromised motility nor the serious loss of cognition. Its best score is reached in reducing the need of institutionalization. Its efficiency is lower, but good when the improvement of behaviour, mood and affectivity is considered. The same is true when intellectual ability and necessary skills for the Activities of Daily Live (ADL) are under question. In general, a careful personalization of the treatment and a high degree of standardization seems to be unavoidable to reach the best results.

In summary, a personalized rehabilitative approach to the older subject affected by cognitive impairment should be regarded as sufficiently efficient, and poorly expensive in comparison with traditional care. According to the Authors, it should be affordable and economy saving even for developing countries.

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