Interpretation of the findings
disability, dementia, Dementia
Dementia is a progressive condition with no cure. In recent years, interest in preventing dementia has been increasing.We found improvements in some aspects of cognitive function, but these were small, and the analyses were underpowered. Any benefits did not contribute to better functional ability. Cognitive stimulation was not used in our intervention, apart from dual task training, which can be considered to be training in divided attention. The occupational therapy approach was a form of cognitive rehabilitation.Current health policy emphasises living well after a dementia diagnosis, through a combination of healthcare, psychosocial and societal changes, and adaptation of services to meet the particular needs of people with dementia.The absence of measurable health gain makes it hard to argue for routine provision of this intervention. Our observations could, however, inform the development of future models of support. A widespread perception exists of a service gap for people after a dementia diagnosis and their carers. The healthcare background and knowledge and expertise of the therapists seems to have been relevant to delivering holistic and supportive intervention. What this means in terms of measurement and evaluation is yet to be defined, but our current paradigm may be missing something. Others have commented on the unsuitability of available outcome measures and the limitations of randomised controlled trials in evaluating interventions in this population.Some specific aspects of our trial may explain negative results. The disability assessment for dementia scale is recommended as the most appropriate activities of daily living outcome for dementia trials, but it can be difficult to complete. The scale distinguishes between initiation and performance of activities, and privileges activities undertaken without prompting. Although reasonable on a normative basis, this privileging of unsupported activity may not adequately ascertain supported performance rather than independence. We undertook training in dual task activities, as impairment in these is a risk factor for falling, they are trainable, and improved abilities can carry over between activities.We can speculate whether control group participants who receive a diagnosis of dementia and who are sufficiently able to volunteer for a research study, successfully adapt, drawing upon their existing resources and striking a balance that works for them in terms of activity and wellbeing. The objective of the trial was to introduce an intervention that did something different. Frequent involvement of healthcare professionals could, however, disrupt normal adaption, draw attention to ill health rather than wellbeing, encourage people to take greater risks than they would usually have done, and prompt greater involvement of healthcare services. The intervention which the control group received was more than would be delivered to people with dementia in routine practice but was less than is established to reduce the risk of falls or improve executive function and involved substantially less professional contact than the intervention group received. The rationale was to improve retention in the control group by avoiding the resentful disengagement reported in some trials. The calendar data indicated that the intervention group exercised substantially more than the control group. Furthermore, in our three arm feasibility trial, an intervention comprising 13 visits over three months proved inadequate to enable participants to sustain activity and engagement, so it is unlikely that the few sessions of the control condition in this trial would do so.