| HOME | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|---|
| ||||||||||||||||||||||||||||||||
a Department of Psychiatry and Behavioural Sciences, University College London, London, England
b Services for Older People, Princess Alexandra Hospital, Harlow, Essex, England
c Institute of Medical and Social Care Research, University of Wales Bangor, Gwynedd, Wales
d University College London, Department of Psychiatry and Behavioural Sciences, London, England
Correspondence: Martin Orrell, Reader in Psychiatry of Ageing, University College London, Department of Psychiatry and Behavioural Sciences, Wolfson Building, 48 Riding House Street, London W1N 8AA England. E-mail: m.orrell{at}ucl.ac.uk.
Decision Editor: Vernon L. Greene, PhD
 |
Abstract |
|---|
 TOP Abstract MethodsResultsDiscussionReferences |
|---|
The evidence indicates that RO has benefits on both cognition and behavior for dementia sufferers. However, a continued program may be needed to sustain potential benefits. Future research should evaluate RO in well-designed multicenter trials.
Key Words: Memory impairment • Alzheimers • Cognition • Behavior • Therapy
Reality orientation (RO) was first described (Taulbee and Folsom 1966
) as a technique to improve the quality of life of confused elderly people, although its origins lie in an attempt to rehabilitate severely disturbed war veterans. RO involves the presentation of orientation and memory information, relating, for example, to time, place, and person. This was thought to provide the person with a greater understanding of his or her surroundings, possibly resulting in an improved sense of control and self-esteem. Before this there had been little research on psychological therapies for dementia (Cosin, Mort, Post, Westropp, and Williams 1958). The early RO work marked the advent of the use of psychological therapies in the care of dementia, which had previously been seen primarily as a medical problem with medical interventions.
RO can be of a continuous 24-hr type, whereby staff involve the patients in reality-based communication in every contact throughout the day, or "classroom RO," where groups of people meet on a regular basis to engage in orientation-related activities. A prominent focus of classroom RO is often the "RO board," which typically displays information such as the day, date, weather, name of next meal, and other details (Holden and Woods 1995). There have been a number of studies on classroom RO since Taulbee and Folsom 1966, many reporting positive findings. For example, improvements were reported in "orientation to reality and in motivation toward selfcare, responsibility and social involvement" (Salter and Salter 1975, p. 406). Controlled studies have shown varied results. Some authors have found that classroom RO can lead to some improvements in cognitive function, with no effect on behavior (e.g., Hanley, McGuire and Boyd 1981), whereas others have found positive effects on behavior, with no significant changes in cognition (Baines, Saxby, and Ehlert 1987). There has been criticism of RO in clinical practice, with concern that it has sometimes been applied in a mechanical fashion and has been insensitive to the needs of the individual (e.g., Powell-Proctor and Miller 1982). Moreover, it has been argued that constant relearning of material can actually contribute to problems in mood and self-esteem (Butler and Lewis 1977). In recent years, RO has lost some of its popularity, but nevertheless a number of its principles have been incorporated into everyday clinical practice (e.g., RO boards). In many settings, it has been overtaken by more popular developments such as validation therapy (Feil 1971), which is not primarily memory oriented. There has also been increasing interest in the use of cognitive rehabilitation for people with dementia (e.g., Quayhagen and Quayhagen 1989). Thus, a reconsideration of the efficacy of RO is timely.
RO studies have often been small in size and of variable quality, making the effectiveness of RO open to debate, due to the lack of a sound evidence base. There has also been a lack of clear guidance for clinicians and practitioners, and little consistent application of psychological therapies like RO in dementia services. The aim of this study was to conduct a systematic review of RO trials in dementia. It was carried out under the auspices of the Cochrane Collaboration Cognitive Impairment and Dementia group, based in Oxford, United Kingdom.
|
Methods |
|---|
|
TOPAbstractMethodsResultsDiscussionReferences |
|---|
, the Cochrane Database of Systematic Reviews 1998, OMNI (Organising Medical Networked Information), BIDS (Science Citation Index and Social Science Citation Index, 1994), Dissertation Abstracts International: 1861–1997, and SIGLE (System for Information on Grey Literature). We searched internet sites for relevant information: Healthweb, including Medweb (Mental Health Infosource, American Psychiatric Association, Internet Mental Health, Mental Health Net), and the National Health Service Confederation. The following journals were handsearched: Aging and Mental Health, The Gerontologist (1961–1994), Journals of Gerontology (1960–1978), Current Opinion in Psychiatry (1988–1997), and Current Research in Britain, Social Sciences (1991–1995). In addition, we searched in the Alzheimer's Disease Society library, and letters were published in PSIGE magazine (Psychologists Special Interest Group in the Elderly) and The Psychologist, the journal of the British Psychological Society, requesting information on any RCTs which might otherwise be missed, such as unpublished papers. Bibliographies of all relevant articles were scanned, and an optimally sensitive search strategy was additionally performed by a coreviewer. Experts in dementia care were consulted.
Inclusion Criteria
Studies
All RCTs examining the effect of RO for dementia were initially included. Authors were contacted for missing data, such as details of randomization, means, and standard deviations.
Participants
Participants were elderly people (mean age >55) diagnosed with dementia (cognitive impairment, Alzheimer's disease, organic brain syndrome, etc.) according to the Diagnostic and Statistical Manual of Mental Disorders (4th ed., American Psychiatric Association 1994), International Classification of Mental and Behavioral Disorders (10; World Health Organization 1992), or comparable. For inclusion, it was necessary for more than 60% of the participants to have completed the study.
Interventions
Participants attended regular therapy groups (at least 10) for a minimum period of 3 weeks. These groups from 30–60 min, involving (among other cognitive activities) the presentation, repetition, and use of orientation information (time, place, and person related). There was a minimum of 4 participants in each group.
Outcome measures
Cognitive and/or behavioral outcome measures were necessary for entry into the review.
Data Extraction
Descriptive characteristics (such as quality of randomization and blinding) and study results were extracted by means of a standard data extraction form. Additionally, letters and E-mails were sent to all authors of controlled trials asking for essential information (statistics and/or details of randomization). Data were extracted from psychometric tests measuring changes in cognition and behavior. Where possible, the data were independently pooled across studies. In some cases, trials used more than one scale to measure similar outcomes (Baines et al. 1987). For the purpose of meta-analysis, it was only possible to use one scale from each study. Cognitive tests were chosen by using the following criteria (in decreasing order of importance): (a) well-recognized published cognitive tests; (b) orientation tests; (c) short-term memory tests; (d) information tests; (e) any test of cognition using some of b–d. Behavioral tests were selected using the following criteria (in decreasing order of importance): (a) well-recognized, published behavioral tests and (b) primarily tests of activities of daily living/adaptive social behavior. Discussion between the two reviewers and the other authors were used to resolve any queries.
Analyses
RevMan 3.0 (Update Software 1996) was used. Analyses were adjusted to the random effects model, due to the heterogeneity of trials. Because trials used different tests to measure the same outcomes, standardized mean differences (SMDs) were used. These were calculated by dividing the difference between the treatment and control means by the pooled standard deviation within each study, thus enabling them to be compared with the other trials in a standardized way.
|
Results |
|---|
|
TOPAbstractMethodsResultsDiscussionReferences |
|---|
). The other 7 controlled trials all included the term(s) randomized, randomly assigned, or similar. We decided that this was acceptable for inclusion into the review. Therefore, eight RCTs were included in the analysis.
Quality of Included Studies
The quality of each study was assessed according to the four criteria outlined in the Cochrane Collaboration Handbook (Mulrow and Oxman 1996): selection bias, performance bias, attrition bias, and detection bias. Details of randomization concealment (detection bias) can be seen in Table 1 . In view of the lack of detailed information on methods of randomization, we did not assign a formal quality score to the studies.
|
; Wallis, Baldwin, and Higgenbotham 1983) both stated that the staff were unaware of the allocation of patients to groups, as they were removed from the setting for treatment. There was no evidence of blinding in the other studies. How far patients were blind to treatment remains a controversial issue. This would depend on how much information was given to them and their level of comprehension. Most authors said that the RO groups were held in separate areas, reducing the chance of contamination (Baines et al. 1987; Ferrario et al. 1991; Hanley et al. 1981; Wallis et al. 1983; Woods 1979). The groups may have been held in separate rooms in the other studies, although this information was not provided. The nature of the biases and differences between studies (such as length and content of RO sessions) were considered as variables affecting outcomes and are discussed subsequently.
Meta-Analysis
Out of the eight studies, only six could be entered into "Metaview" (the Cochrane term for meta-analysis). The other two studies (Baldelli et al. 1993; Hanley et al. 1981) did not include the means and standard deviations on tests before and after the intervention, which were needed for the analysis. The authors were contacted with no response. From these six RCTs there was a total of 125 participants (67 in experimental groups, 58 in control groups).
The overall results in the cognition section were significantly in favor of treatment (Fig. 1). The standardized mean difference was -0.59, with a 95% confidence interval (CI) of -0.95–-0.22. Comparing the standardized mean difference with a normal distribution indicated that the average score for patients in the treatment groups was better than 72% of the control patients' scores. All studies contained cognitive measures, with a total of 125 participants.
|
). These results (on the Mini Mental State Exam) were significant in favor of treatment 
. For the other studies, statistics were as follows: Using the Weschler Memory Scale, 
(Woods 1979); using the Information/Orientation subscale of the Clifton Assessment Procedures for the Elderly (CAPE; Pattie and Gilleard 1979), 
(Baines et al. 1987); using the Information/Orientation subscale of the Clifton Assessment Schedule (CAS; Pattie and Gilleard 1976), 
(Ferrario et al. 1991); using the Orientation subscale of the Kingston Dementia Rating Scale (KDRS), 
(Gerber et al. 1991); and using the cognitive subscale of the Royal College of Physicians (RCP; Hodkinson 1973), 
(Wallis et al. 1983). These results were not individually significant (confidence intervals overlapping zero); in all, the trend favored treatment (implying a negative value for the SMDs).
The total result for behavior was again significantly in favor of treatment (see Fig. 2). The SMD was -0.64, with a 95% CI of -1.20–0.08, with a total of 57 subjects (33 experimental, 24 control). Comparing the SMD with a normal distribution indicates that the average score for patients in the treatment groups was better than 74% of the control patients' scores. All individual studies had insignificant results, but the trends were again in favor of treatment. Statistics were as follows: using the Crichton, 
(Wallis et al. 1983); using the Self-Care Functioning subscale of the MOSES (Helmes, Csapo, and Short 1987), 
(Ferrario et al. 1991); using the Crichton, 
(Woods 1979); and using the Behavioural subscale of the CAPE, SMD = -1.32, 95% CI = -2.77–0.12 (Baines et al. 1987).
|
|
Discussion |
|---|
|
TOPAbstractMethodsResultsDiscussionReferences |
|---|
). Trials varied greatly in factors such as length of intervention, methodological quality, and outcome measures. However, the results showed that RO had significant positive effects on both cognition and behavior. Results for cognition were more precise, due to a sample size of 125, compared with 57 for behavior.
The study (Ferrario et al. 1991) in which participants received much more RO than any of the other trials (105 hr in total) had the highest cognitive SMD (-0.96) in favor of treatment; however, our results did not show a clear relationship between amount of intervention and cognitive outcome. Additionally, the trial (Breuil et al. 1994) in which participants were given the least amount of RO (10 hr) was the only one to yield significant positive findings favoring RO. Many of the smaller RO trials are vulnerable to Type II statistical error due to insufficient numbers. Similarly, the results did not show a relationship between amount of intervention and behavioral outcome, or a pattern between length of sessions and outcomes.
The overall SMD (-0.59) was of a similar size to the SMD (-0.71) of the Breuil et al. 1994 study, which found a 2.1-point benefit on the Mini Mental State Exam for the stimulated group compared with the control group. Because Mini Mental State Exam scores are thought to decline by on average 4 points per year for dementia, the benefits of RO might equate to a 6-month delay in the usual cognitive deterioration. How far such a delay is of functional benefit to an individual patient would necessarily vary. The orientation process used by Breuil et al. 1994 study slightly differed from the other studies (see Table 1 ), being more advanced theoretically than the 1970s concepts, as much more was known about the neuropsychology of dementia. Their techniques were more akin to the sophisticated cognitive rehabilitation programs used in brain injury.
There was variation in the alternative activities offered to control groups, with some trials giving them no treatment (Baines et al. 1987; Breuil et al. 1994; Ferrario et al. 1991) and others providing control groups with some alternative social therapy (Gerber et al. 1991; Wallis et al. 1983; Woods 1979). Our results showed no effects of these differences on outcome, suggesting that the actual qualities of RO, rather than merely the therapeutic effect of social contact and attention, may affect individual outcomes. However, staff may have had greater expectations from the RO group, which may have affected participants' performance.
There were 38 dropouts in the six studies with available data. In one study (Wallis et al. 1983), there were 22 dropouts, but no details were provided as to which groups they were in. Of the remaining 16, there were details of 8 RO participants and 6 controls. From these, it was clear that 3 experimental participants and 3 controls died; others, for example, went to the hospital or were discharged. Hence, there was no evidence in this study that RO had serious side effects. However, cases of adverse psychological and emotional effects in patients have been reported (Dietch, Hewett, and Jones 1989). It has even been stated that "challenging their fantasies or attempting to educate and continually re-educate people with dementia is probably of no value" (Reisberg 1981, p. 149).
There has been some evidence that RO patients actually performed worse at a 10-week follow-up than before treatment (Gerber et al. 1991), suggesting that benefits gained from RO were lost. Conversely, another study found that participants gained higher scores in both cognitive and behavioral tests 1 month postintervention (Wallis et al. 1983). The present analysis has provided no clear evidence of the long-term benefits of RO primarily because of a lack of follow-up data. It has been suggested that for RO to have more lasting effects, there should be a detailed schedule of reinforcement and follow-up, with a continuous, ongoing program. For example, low-key interventions like RO boards and signs could be used when a person is disoriented and distressed. The introduction of a 24-hr RO program might be a good way to retain what has been learned if the continuation of classroom RO is not feasible (Williams, Reeve, Ivison, & Kavanaugh, 1987).
With psychological interventions, unlike drug trials, double blinding is not possible and contamination between groups is more likely. Hence RCTs may be especially valuable if used in conjunction with more qualitative studies, such as case studies, or quasi-experimental studies in which different treatments are carried out in different centers. These may offer a greater insight into the most effective features of RO, the most effective ways in which it may be applied, and the types of people most suited. As with all psychological interventions, the success of RO may be dependent on it being used at the appropriate time, by sensitive and experienced practitioners, to receptive patients.
Future research should investigate the relationship between classroom and 24-hr RO; other outcomes, such as quality of life; more individualized psychological treatment approaches for people with dementia, with more detailed assessments of everyday memory skills and their remediation in individual programs; and how long the benefits of RO remain after treatment and whether continuation therapy is effective. In summary, this review found that classroom RO had clear benefits to patients with dementia in both cognitive and behavioral domains, suggesting that RO techniques should be considered as an important component of dementia care. The benefits of short-term RO may only be short lived, but a more long-term program may help sustain improvements. This review has shown that RCTs are possible in this field but that there is a need for multicenter trials of better quality and design methodology that include a clear rationale for the interventions used. We have recently been awarded grants to conduct a multicenter trial.
|
Acknowledgments |
|---|
Received for publication October 1, 1998. Accepted for publication November 30, 1999.
|
References |
|---|
|
TOPAbstractMethodsResultsDiscussionReferences |
|---|
This article has been cited by other articles:
 |
|
 |
|
  P. Y.F. Chung, C. Ellis-Hill, and P. G. Coleman Carers perspectives on the activity patterns of people with dementia Dementia, August 1, 2008; 7(3): 359 - 381. [Abstract] [PDF]
|
|
|
|
 |
|
 G. ONDER, O. ZANETTI, E. GIACOBINI, G. B. FRISONI, L. BARTORELLI, G. CARBONE, P. LAMBERTUCCI, M. C. SILVERI, and R. BERNABEI Reality orientation therapy combined with cholinesterase inhibitors in Alzheimer's disease: randomised controlled trial The British Journal of Psychiatry, November 1, 2005; 187(5): 450 - 455. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 J. Olazaran, R. Muniz, B. Reisberg, J. Pena-Casanova, T. del Ser, A. J. Cruz-Jentoft, P. Serrano, E. Navarro, M. L. Garcia de la Rocha, A. Frank, et al. Benefits of cognitive-motor intervention in MCI and mild to moderate Alzheimer disease Neurology, December 28, 2004; 63(12): 2348 - 2353. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
A. SPECTOR, L. THORGRIMSEN, B. WOODS, L. ROYAN, S. DAVIES, M. BUTTERWORTH, and M. ORRELL Efficacy of an evidence-based cognitive stimulation therapy programme for people with dementia: Randomised controlled trial The British Journal of Psychiatry, September 1, 2003; 183(3): 248 - 254. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 R T Woods, E. Moniz-Cook, S. Iliffe, P. Campion, M. Vernooij-Dassen, O. Zanetti, and M. Franco Dementia: issues in early recognition and intervention in primary care J R Soc Med, July 1, 2003; 96(7): 320 - 324. [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||
| HOME | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|---|
