Original Article

Journal of Geriatric Psychiatry

and Neurology
Efficacy of Cognitive Rehabilitation in 1-8
ª The Author(s) 2018
Article reuse guidelines:
Alzheimer Disease: A 1-Year Follow-Up Study sagepub.com/journals-permissions
DOI: 10.1177/0891988718813724
journals.sagepub.com/home/jgp

Sophie Germain, PhD1, Vinciane Wojtasik, BErgo1,

Françoise Lekeu, PhD1, Anne Quittre, MPsy1, Catherine Olivier, BErgo1,
Vinciane Godichard, MPsy1, and Eric Salmon, MD, PhD2

Abstract
Introduction: The benefit of cognitive rehabilitation (CR) for patients with early-stage Alzheimer disease (AD) remains difficult
to assess. Method: An observational, prospective study was conducted in a sample of 52 patients with AD included in a clinical,
individualized CR program. Cognitive rehabilitation consisted of 1 weekly session during 3 months at home, followed by
1 monthly contact for 9 months. Rehabilitation techniques were used by experienced therapists to adapt activities important for
the patient. Evaluation of patient’s dependence in activities and objective and subjective caregiver’s burden was performed with a
research quantitative scale immediately after the intervention and at 6-month and 1-year follow-up. Results: Analyses with
repeated measure analysis of variance showed decreased patient’s dependence for adapted activities at 3 months, 6 months, and
1 year. Objective and subjective percentage of caregiver’s burden was also decreased at all evaluations with our research
functional scale, while there was no change on Zarit’s burden scale. Global cognition slightly decreased over 1 year. Conclusions:
This observational study in a clinical setting is in line with the benefit of CR for patients with mild AD reported in recent ran-
domized controlled trials. The benefit obtained for adapted activities remained after 1 year, even if global cognition declined.
Moreover caregiver’s burden related to all individually relevant daily activities (from a list of 98) evaluated within the CR program
was decreased after 1 year. Those preliminary results emphasize the importance of choice for the measurement instrument to
report CR efficacy and claim for further validation of such tools.

Keywords
cognitive rehabilitation, memory clinic, Alzheimer, daily activities, burden

Introduction with well-defined experimental design. Effectively, discrepan-

cies between studies are notably due to the fact that nonphar-
Alzheimer disease (AD) is characterized by progressive decline
macological interventions included a range of very different
in cognitive, social, and functional abilities and by neuropsy-
procedures. Focusing on cognitive approaches, classification
chiatric disturbances.1 There is a high prevalence of patients
and definition of procedures have been proposed.8 Accord-
affected by AD.2 Consequently, care for these patients con-
ingly, cognitive interventions include cognitive training, cog-
cerns a substantial number of individuals and represents a com-
nitive stimulation, and cognitive rehabilitation. Cognitive
pelling economic challenge.3 Moreover, AD impacts not only
training is a specific approach that involves a repeated and
people with dementia themselves but also the relatives and
structured teaching of strategies devoted to specific domains,
more specifically the caregiver.
such as attention for example.5 Cognitive stimulation is a gen-
The efficacy of current symptomatic medications such as
eral approach comprising engagement in a range of activities
cholinesterase inhibitors and memantine for the treatment of
aiming to improve general cognitive and social functioning.9
AD is limited to delaying the progression of symptoms.4 How-
Cognitive rehabilitation (CR) is an individualized approach
ever, some studies suggest that combining behavioral method
that helps individual people with cognitive impairments by
and pharmacological treatment may optimize benefit for
patient and caregiver,5 underlying the importance to develop
nonpharmacological intervention programs. 1
Memory Clinic, Department of Neurology, C.H.U. Liège, Liege, Belgium
2
Some studies showed that nonpharmacological interven- GIGA Cyclotron Research Centre, University of Liege, Liège, Belgium
tions could reduce the frequency and severity of dementia
Corresponding Author:
symptoms,6 while others failed to demonstrate such effects or Eric Salmon, Memory Clinic, Department of Neurology, C.H.U. Liège, Quai
showed only passing effects.7 These discrepancies between Godefroid Kurth 45, 4000 Liege, Belgium.
studies called for the development of more specific program Email: eric.salmon@uliege.be
2 Journal of Geriatric Psychiatry and Neurology XX(X)
improving functional ability, enabling people to attain person-
ally relevant goals, and maximizing family or social participa-
tion.8,10 Cognitive rehabilitation goes beyond the cognitive
deterioration per se and focuses on its functional and social
impact on everyday functioning. Furthermore, as the purpose
of CR is to improve patient’s autonomy, it also aims to decrease
caregiver’s burden. Actually, numerous studies showed that
caregivers of patients with AD experience high level of burden
and psychological distress.11
Cognitive training and cognitive stimulation may have mod-
est effects on cognition but failed to demonstrate significant
functional benefit and to show generalization to other domains
than the ones trained.7,12-14 This could, partially at least, be
explained by the neurodegenerative process per se. In fact, both
cognitive training and cognitive stimulation require some
learning, recalling, and controlled cognitive strategies, that is,
processes that are impaired by the brain pathology. By way of
contrast, the focus of CR is not to enhance cognitive function
but to develop and implement the use of new strategies that rely
on preserved capacities or that are relatively less cognitively
demanding (such as using agenda or other external memory
aids). Herein, individualized CR seems to be promising for
maintaining adapted daily activities15-17 as further demon-
strated in most18-22 but not all23,24 recent controlled trials.
There were effectively discrepancies and limitations in pre-
vious randomized controlled trials (RCTs) that included parti-
cipants with mild to moderate AD. Two trials 23,24 (that
included, respectively, 90 and 8 participants for CR) using a
program of 12 weekly 1-hour sessions provided in the clinic
failed to show improvement in instrumental activities of daily
living (IADLs) measured at 3 and 9 months with the Bayer
ADL scale.25 The authors stressed insufficient personalization
of the intervention, poor transfer into the real-life setting, and
low sensitivity of assessment instruments as possible methodo-
logical limitations. Most other studies reported benefit in daily
functioning for trained activities and for a relatively short delay
of 219,22 or 3 months.20 Randomized controlled trials com-
prised between 20 and 69 participants who benefited from
1 or 2 weekly sessions for CR, and IADLs were respectively
evaluated with the Canadian Occupational Performance Mea-
sure,26 the measurement of everyday cognition,27 or the ADL
situational test.28 In another trial,18 156 patients who benefited
from CR (12 weekly 90 minutes sessions during 3 months,
followed by a maintenance session every 6 weeks for the next
21 months) showed a lower reduction in functional ability than
controls after 3 months and 2 years (measured with the disabil-
ity assessment of dementia29), and caregiver’s score on Zarit
burden scale30 was lower than in the control group. Accord-
ingly, there is need for refined instruments adapted to measure-
ment of daily activities performance and caregiver’s
experience that could make sense and remain sensitive in
long-term evaluations.
In this context, we used a research daily activities measure-
ment tool in a CR clinical program that aimed at enabling
people with AD and their primary caregivers to improve their
daily life functioning at home and to be more integrated in
social life. Our observational, prospective population study in
a sample of patients with mild dementia aimed at evaluating
feasibility and reproducibility in clinical routine of results pre-
viously obtained for CR in more conventional trials showing
significantly improved patients’ autonomy but also at assessing
caregivers’ burden immediately after the 3 months intervention
and after 1-year follow-up, when global cognition might be
deteriorating.
Population and Methods
Participants
Among recently diagnosed patients, about 50% met criteria for
CR (mild to moderate dementia, living at relative proximity of
the memory clinic, willing to maintain daily activities at home
with the help of a relative, and without excessive mood dis-
order). About 50% of them declined CR because they could not
conceive which activity might be adapted, they did not have
time or interest for learning new strategies, or they did not
recognize the importance of their difficulties. Fifty-two
patients living at home were included in a program of cognitive
rehabilitation (Memory Center, CHU of Liège, Belgium) and
were followed over 1 year. Mean age was 73.2 + 8.4 years. Of
the participants, 51% were women. The clinical diagnosis was
probable AD1 with or without associated vascular brain pathol-
ogy (mixed dementia), and patients had mild to moderate
dementia severity according to their Mini-Mental State Exam-
ination score (to obtain informed consent and to ensure that
participants had a sufficient level of cognitive functioning for
taking part into the CR). Exclusion criteria were other degen-
erative diseases such as Lewy body dementia, depression, and
significant medical condition that could interfere with rehabi-
litation. Social–economical levels were well distributed (23.2%
level 1, 34.8% level 2, and 39.3% level 3). Most (65%) patients
took an acetylcholinesterase inhibitor. A participant’s care-
giver was required to obtain reliable information about the
everyday functioning and to measure the effect of the interven-
tion on caregiver’s well-being. Caregiver was spouse in 75% of
participants. A limitation was that, for practical organizational
reasons, the same 4 specific therapists (psychologists and/or
ergotherapists with 15-years experience in CR) conducted the
intervention and the assessments at baseline and at 3, 6, and 12
months of follow-up. By doing so, all participants and care-
givers performed all assessments. Patients were included into a
rehabilitation convention supported by the Belgian health sys-
tem (www.inami.fgov.be/fr/themes/cout-remboursement/
maladies/troubles-mentaux-neurologiques). The study was
approved by the University Ethic Committee; written informed
consent to participate was obtained from the patient and the
relative; and activities adapted in the CR program were men-
tioned in a written contract.
Design of the program
The CR program consisted of 1 weekly individual session
during 3 months. Initial (T1), postintervention (T2; 3 months),
Germain et al
6-month follow-up (T3), and 12-month follow-up (T4) assess-
ments were carried out for each participant. The CR program
consisted of 5 specific steps.
The first step was to identify difficulties in daily life activ-
ities that were important and relevant for the patient and the
relatives using the PROFINTEG research tool.31 This tool was
used to determine the level of performance in daily life activ-
ities and to identify the presence of specific difficulties (see
below). This tool also allowed evaluating the importance of the
task for the patient and the corresponding objective and sub-
jective caregiver’s burden if the task was not well achieved. In
a preliminary validation, it showed excellent interrater reliabil-
ity and sensitivity to changes in IADL disability over time.31
The second step was to select the activities for which adap-
tation was realistic and potentially rewarding. Several factors
were decisive to make an appropriate choice: the preserved
capacities of the patient and the possibility to use them to
facilitate learning, the possibilities of the therapist (for exam-
ple, rehabilitation of driving was excluded), and the risk asso-
ciated with a given activity. Among the most frequently
adapted activities, we can cite developing memory aids as
agenda, calendar, notes to remember daily tasks and appoint-
ments, kitchen activities, use of electronic devices, or adapting
technologies of communication.
Third, a specific program to adapt each selected activity was
defined. This step required a fine and detailed analysis of the
way the activity was performed, including the observation of
the activity in a naturalistic environment (most frequently at
home). This was absolutely necessary to understand why and
when the difficulties arose.32 So, the adaptation consisted in
defining a new strategy allowing to improve the realization of
the activity according to the specific abilities and difficulties of
the patient.33
The CR by itself consisted of 60-minute weekly individual
sessions carried out at home during 3 months, using specific
techniques according to the objective. As recommend, errorless
progressive adaptation 34 and spaced retrieval technique 35
were frequently used for progressive acquisition of a new abil-
ity or a new procedure. Written instructions were used with
step-by-step procedure, and repeated exercises were provided
where each step had to be mastered by the patient before mov-
ing to the next one.36 Furthermore, an adaptation of the envi-
ronment was frequently required.
Finally, to ensure a good practice of the activity at home,
relatives were explained the procedure. They were explained
the importance to maintain the procedure as a routine and to
intervene only when it became necessary (consequently
accepting a given slowness in task realization). There was
no practice journal after the CR program, but 9 additional
individual contacts were maintained (almost every month
according to need and availability of the participants, with a
total of 21 contacts over 1 year) to ensure that the routine
activities were well performed and to reexplain strategies if
necessary. A proof of concept of cost utility analysis was
favorable to CR.37
3
Measures
The Profinteg scale is a research scale that focuses specif-
ically on impairment in IADLs (currently 98 IADLs; see
Table 1) due to cognitive deficits, in order to efficiently
guide an ecological cognitive rehabilitation of IADL and
evaluate progress made on these activities.31 We only used
the caregiver’s version of the scale. The caregiver had to
identify and estimate the difficulties (see grid for evaluation
in Figure 1) in each of 98 daily life activities (the total score
corresponded to the severity of reported difficulties, with
0 point if no difficulties; 1 point for lack of activity initia-
tion, omission of 1 or several steps, or wrong execution of
one or several steps; 4 points corresponding to perseveration
errors; and 5 points if the activity could not be carried out;
points were summed over all the assessed activities and
expressed in percentage of the maximal dependency score).
Furthermore, caregivers had to evaluate the objective (time
spent to palliate patient’s deficit) and subjective burden (the
arduousness to assume the problematic activity or to aid the
patient in its realization) resulting from these activities (on a
scale ranging from 0 to 3; points were summed over all the
assessed activities and expressed in percent of the maximal
score).
The Burden Interview30 was also administered as a global
burden measure. The revised version of this caregiver self-
report measure contains 22 items. Each item is a statement
examining burden associated with functional/behavioral
impairment or the home care situation, focusing on the affec-
tive response of the caregiver. The caregiver is asked to
endorse each statement using a 5-point scale, from 0 (never)
to 4 (nearly always).
The Mini-Mental State Examination (MMSE)38 was used
to assess global cognitive deterioration. In MMSE, 30 ques-
tions and tasks are proposed addressing different cognitive
abilities, and both evaluation and quotation are well struc-
tured. The greater the score, the milder the cognitive
deficit.
Data analyses
The primary goal of this observational study was to determine
the effect of CR on the patient’s dependence in daily activities.
In order to test an expected reduced dependence over time due
to engaging in CR, repeated measure analyses of variances
(ANOVAs) were conducted. They were separately conducted
on patients’ global dependence score of the Profinteg Scale and
on dependence score on the specific adapted activities from the
Profinteg Scale at 4 time points (baseline, 3-, 6-, and 12-month
follow-up). We also evaluated the modification of burden over
time (baseline, 3-, 6-, and 12-month follow-up) using repeated
measure ANOVAs, separately conducted on the Profinteg
score of objective and subjective charge. Finally, separate
repeated measures ANOVAs were conducted on Zarit’s burden
score and MMSE score over time (the later to objectively mea-
sure the evolution of the cognitive status over time). Analyses
4 Journal of Geriatric Psychiatry and Neurology XX(X)

Table 1. Listing of Daily Activities Assessed With the Research Tool. Table 1. (continued)

Food-Related Activities Moving

1. Preparing a meal (usual) 52. Using public transportation (habitual trip)
2. Preparing a meal (new) 53. Using public transportation (new trip)
3. Reheating/Defrosting food 54. Travelling using a bike (habitual trip)
4. Cooking pastry 55. Travelling using a bike (new trip)
5. Using a coffee machine 56. Having a walk (habitual trip)
6. Using a Senseo (or likely) machine 57. Having a walk (new trip)
7. Using a coffee maker Management activities
8. Using a pressure-based coffee maker 58. Scheduling an appointment
9. Preparing filter coffee 59. Going to an appointment
10. Preparing soluble coffee 60. Managing (postal) mails
11. Preparing packaged tea 61. Sending (postal) mails
12. Preparing unpackaged tea 62. Filling in a form
13. Setting the table 63. Going to an administrative counter
14. Clearing the table 64. Carrying out a payment via a bank transfer
15. Doing the dishes 65. Using a cash dispenser
16. Using a dishwasher 66. Carrying out an electronic bank transfer
Medication-related activities 67. Carrying out a payment using the internet (credit card)
17. Preparing a pillbox 68. Carrying out a payment using a phone (phone banking)
18. Using a pillbox 69. Transferring money between one’s own bank accounts
19. Taking medicine without a pillbox 70. Using cash
Homework (in a broad sense) 71. Using a debit card
20. Removing dust 72. Managing energy
21. Vacuum cleaning Leisure activities
22. Sweeping up 73. Doing crosswords
23. Cleaning the soil 74. Doing a jigsaw puzzle
24. Cleaning the toilets 75. Playing manual solitaire
25. Cleaning the windows 76. Doing a sudoku
26. Sorting the rubbish 77. Playing scrabble
27. Getting out the rubbish 78. Drawing/Painting
28. Washing clothes 79. Taking silver photos (automatic camera)
29. Ironing 80. Taking silver photos (manual camera)
Shopping activities 81. Taking digital photos
30. Compiling a shopping list 82. Using a radio
31. Purchasing 83. Using a CD player
Looking after domestic animals, plants, and the garden 84. Using a record-player
32. Taking care of animals 85. Using an audio-cassette player
33. Watering plants 86. Watching television
34. Mowing the grass 87. Recording a television program on a videotape
35. Working in one’s kitchen garden 88. Watching a videotape
36. Working in one’s ornamental garden 89. Watching a DVD
Knitting and sewing 90. Using a computer: general functions
37. Knitting 91. Using a computer: word processing (MS Word®)
38. Sewing: repairs and hems 92. Using a computer: tables and graphs (MS Excel®)
39. Sewing: ready-to-wear clothes 93. Using a computer: displaying digital photos
Using the phone 94. Playing computerized solitaire
40. Dialing a phone number 95. Surfing the internet
41. Receiving a phone call 96. Sending and receiving electronic mails
42. Managing a phone call 97. Reading
43. Leaving a voicemail on a phone Organization
44. Checking a voicemail on a phone 98. Storing objects (keys, etc.)
45. Dialling a mobile phone number
46. Receiving a mobile phone call
47. Managing a mobile phone call
48. Leaving a voicemail on a mobile phone were conducted with Statistica version 13. Size effect was
49. Checking a voicemail on a mobile phone assessed with partial Z2, considering .02 as small, .13 as
50. Sending a SMS medium, and .26 as large effect. For the sake of completeness,
51. Reading a SMS
we also used nonparametric Friedman ANOVA and Kendall
(continued) coefficient of concordance, and similar results were obtained.
Germain et al 5

Figure 1. A grid for the evaluation of daily activities.

Results Table 2. Scores (Mean and SEM) for Different Measures of Efficacy.a

Patient’s Dependency in Daily Activities Baseline Month 3 Month 6 Year 1

Global level of dependency. To test our hypothesis of a reduction Global 21.06 (2.37) 17.33 (2.24) 20.75 (2.94) 24.21 (3.41)
in patient’s global dependency in daily activities over time with dependency
CR, we compared the level of global dependency at baseline, Dependency 49.99 (3.58) 15.22 (2.77) 20.72 (3.06) 24.96 (3.93)
3-month, 6-month, and 1-year follow-up (Table 2). The results in adapted
of the ANOVA revealed a significant reduction in the global activities
Objective 5.48 (0.98) 3.44 (0.54) 3.67 (0.64) 3.80 (0.69)
dependency (F3, 153 ¼ 7.1767, P ¼ .00015, partial Z2 ¼ .123). burden
Complementary analysis showed that reduction was observed Subjective 8.16 (1.24) 4.05 (0.77) 4.20 (0.71) 4.70 (0.83)
at the end of the rehabilitation program, after three months burden
(F1, 51 ¼ 23.51, P < .001). This reduction was followed by Zarit’s score 25.93 (1.84) 26.10 (1.94) N/A 26.43 (2.11)
an increase in dependency over 1 year. Nevertheless, the MMSE 23.20 (0.46) N/A N/A 21.20 (0.78)
dependency level at 1 year remained similar to the baseline Abbreviations: MMSE, Mini-Mental State Examination; N/A, not available; SEM,
level (F1, 51 ¼ 2.62, P ¼ .11). standard error of the mean.
a
Scores in percentage of maximal value, maximum Zarit burden score ¼ 88.

Dependency level for adapted activities. Mean number of adapted

activities was 4.5 + 2.8. To determine the impact of our CR on
those adapted activities (Table 2), a repeated measure ANOVA
comparing the dependency level over time (baseline, month 3,
month 6, and 1-year follow-up) revealed a significant, large
effect size reduction (F3, 153 ¼ 39 882, P < .00001, partial
Z2 ¼ .438). Planned comparisons showed a significant decrease
between baseline and month 3 (F1, 51 ¼ 100.51, P < .001). After
the CR program, there was an increase in dependency from
month 3 to month 6 (F1, 51 ¼ 6.77, P ¼ .012). However, scores
subsequently stabilized from month 6 to 1 year after inclusion
(F1, 51 ¼ 2.55, P ¼ .11), and the decrease between baseline and
1 year was still significant (F1, 51 ¼ 29.54, P < .001).
Burden
Objective burden. Analyses were conducted to estimate the mod-
ification of caregiver’s burden due to CR over time. Repeated
measure ANOVA revealed a significant reduction (F3, 153¼
5.3171, P ¼ .00164, partial Z2 ¼ .094) with a small to medium
effect size. Planned comparisons showed a significant
decreased in objective caregiver’s burden between baseline and
all subsequent measures indicating that the decreased in burden
is lasting (baseline-3 months, F1, 51 ¼ 8.99, P ¼ .004; baseline-
6 months, F1, 51 ¼ 6.12, P ¼ .01; baseline-1 year, F1, 51 ¼ 7.89,
P ¼ .007).
6 Journal of Geriatric Psychiatry and Neurology XX(X)
Subjective burden. Repeated ANOVA on subjective caregiver’s
burden scores revealed a significant decrease in burden after
CR (F3, 153 ¼ 10 943, P < .00001, partial Z2 ¼ .176) with
medium to large effect size. This was observed at the end of
CR (month 3; F1, 51 ¼ 20.73, P < .001). The decrease was
lasting and remained at month 6 (F1, 51 ¼ 19.34, P < .001) and
at 1 year after inclusion (F1, 51 ¼ 13.58, P < .001).
Zarit burden scale. Burden was also evaluated using Zarit scale
at baseline, at month 3, and at 1 year. Statistical analysis
revealed no change of Zarit burden scores (F2, 96 ¼ .30652,
P ¼ .736) after CR.
Global cognition
The cognitive status of patient was evaluated by the MMSE.
One-way ANOVA showed a significant decrease in MMSE
score from 23.2 + 3.0 to 21.2 + 5.2 between baseline and
1 year (F1, 43 ¼ 10.091, P ¼ .00276, Z2 ¼ .190). Note that
MMSE evaluation was not repeated each time to avoid test–
retest learning effect.
Discussion
We observed the evolution of functional abilities in patients
with early dementia who followed an individualized CR pro-
gram. Participants showed a large size improvement in inde-
pendence for personally chosen activities that were adapted to
their individual cognitive capacities. The benefit for those
activities that were important for the patient’s social life was
maintained over 1 year. Cognitive rehabilitation does not aim
at improving cognition and better strategies for daily life activ-
ities were maintained, while global cognition (measured with
MMSE) worsened over 1 year and global autonomy (for non-
adapted activities) did not increase, suggesting no generaliza-
tion of adaptation. Those results obtained in a clinical setting
confirm recent data from RCTs assessing efficacy of CR of
daily activities in mild dementia stages.18-21 The added values
of our report is that decrease in dependence in adapted activ-
ities was ecologically useful at home and highly significant
(large effect size) and was showed to be maintained after 1
year. One RCT also suggested that CR allows to delay institu-
tion,18 but the current study was not designed to assess this
benefit, although all patients were living at home after 1 year
and most followed the CR program in their own environment.
Cognitive rehabilitation has a long tradition, techniques
have been well described, and our population study confirms
several previously published case reports.15
Previous studies could hardly demonstrate the benefit of CR
for caregivers. Accordingly, Zarit evaluation of caregiver’s
emotional burden (feeling about patient’s and own condition)
did not show improvement in our study, although it showed
benefit in a previous RCT.18 However, caregiver’s emotional
burden did not increase either despite mild deterioration of
global cognition in our study. Profinteg instrument was specif-
ically designed for assessing dependence in daily activities31 as
other recent tools does.39 Moreover, it contains caregiver’s
judgment on the importance of the help provided to the patient
(objective care) and on the subjective heaviness of helping
patient managing his tasks. Our results demonstrated a mild
benefit of CR concerning objective burden (since caregiver still
need to provide help for long term maintenance of adapted
activities), and a moderate size benefit for subjective burden,
because caregivers feel more confident in helping the patient.
There are several limitations to our study. It is obvious that
CR is not adequate for any patient.40 Some patients at early
stages already use external memory aids and do not need reha-
bilitation for improving their daily activities, while others are
already unaware of the importance of their daily impairment.41
Few patients are too depressed or anxious to be explained their
dysfunction. On the other hand, CR is not limited to AD, and
participants with vascular or frontotemporal dementia may
benefit from adaptation of their daily activities. It must be
emphasized that collaboration is very important for the success
of the program: When the disease progresses, most procedures
are related to environmental adaptation and caregiver’s adapted
intervention.
Several covariates were not taken into account in our anal-
yses, such as drug treatment. In a pilot study, we observed that
the number of CR sessions was not important as far as the
adapted strategy was well applied by the participant. The clin-
ical condition of the study did neither allow to hire experimen-
ted independent raters nor to distribute roles between therapists
providing CR and evaluating benefit.
The design of our observational study does not allow us to
ascertain that CR is better than any other nonpharmacological
treatment, but demonstration of benefit in the clinical setting
remains important. Cognitive rehabilitation is focused on com-
plaints and activities important for patient and caregiver. We
must acknowledge that an uncontrolled study cannot prove that
the observed changes were due to the specific intervention.
However, the dependency level remained lower after 1 year
for adapted activities, while the global level of dependency
returned to baseline. Cognitive rehabilitation benefit over other
nondrug therapeutic approaches was recently published.18 Our
study provided clues for optimizing CR practice and evalua-
tion, such as intervention at home (when required), consensual
selection of activities to be adapted, and standardized scales for
measuring efficacy of the program. The next step is to further
validate our research functional scale and to use the optimiza-
tions in a well-designed clinical trial. The inclusion of a control
group would allow to clearly attribute the observed effect to the
CR itself.
Acknowledgments
This work was made possible by support from CHU Liège, University
of Liege and King Baudouin Foundation (Fund Maria-Elisa and Guil-
laume de Beys), Belgium.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
Germain et al
Funding
The author(s) received no financial support for the research, author-
ship, and/or publication of this article.
ORCID iD
Eric Salmon, MD, PhD https://orcid.org/0000-0003-2520-9241
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