Current trends in psychotherapies and psychosocial interventions for people with dementia: a scoping review of randomized controlled trials

An outcome of dementia is a progressive decline in cognitive function. Implementing psychotherapies and psychosocial interventions is crucial for bolstering cognitive abilities, promoting independence, and elevating the quality of life for individuals with dementia. This review aims to identify current trends in psychotherapies and psychosocial interventions for people with dementia. A Scoping review was developed based on the framework proposed by Arksey and O’Malley. The literature search was conducted on electronic databases, including Scopus, Cochrane Central Register of Controlled Trials, MEDLINE, CINAHL, Nursing & Allied Health Collection, and MedicLatina. Executed in June 2023, the search focused on articles published in English, Portuguese, and Spanish between 2013 and 2023. Through this search, 1409 articles were initially identified. After selecting and analyzing the reports, sixteen trials were included in this review. Eight distinct categories were identified, covering different strategies. These categories run from computerized game-based cognitive training and reminiscence therapy to compensatory and restorative strategies, memory and attention training, calculation training, dual-task training, counseling, and personalized goal attainment. The findings of this scoping review highlight the diverse landscape of psychotherapies and psychosocial interventions for people with dementia.


Introduction
In the past fifty years, socioeconomic development has been accompanied by significant declines in fertility rates and a simultaneous exponential increase in life expectancy.Consequently, there has been a global phenomenon of population aging (1), with several challenges associated with this aging population (2,3), including dementia (4).
Dementia is a health challenge characterized by a decline in cognitive function, affecting memory, thinking, orientation, comprehension, calculation, learning capacity, language, and judgment.It is a progressive condition primarily affecting older individuals, leading to significant impairment in daily functioning and quality of life (5,6).As the global population ages, the prevalence of dementia in Organization for Economic Co-operation and Development countries is estimated to increase from over 21 million to approximately 42 million individuals in 2050 (7).
As the disease progresses, people with dementia depend on a carer to fulfill their basic needs, resulting in an increased caregiver burden (8).In addition, the behavioral and psychological symptoms associated with dementia, such as depression, agitation, and aggression, entail additional difficulties for caregivers and healthcare professionals (8)(9)(10).
Caregiving for someone with dementia can be overwhelming, leading to burnout and decreased quality of life (8,10,11).The burden of dementia has significant economic implications, with healthcare costs and productivity losses associated with the condition expected to continue to rise (12,13).
Considering the profound repercussions of dementia, there is an urgent need to create efficient interventions targeting both impairment and participation restriction in individuals suffering from this condition.
Although these interventions cannot change the course of the disease, they can support patients to compensate for cognitive deficits and maximize their remaining abilities, addressing both impairment and participation restriction (15).
Combined methods, including both pharmacological and nonpharmacological treatments, have shown significant promise in improving functionality for individuals with dementia.These comprehensive strategies have the potential to slow the progression of the disease, helping individuals maintain their abilities and engage in meaningful activities for a more extended period (16).
Studies by Bahar-Fuchs et al. (17), Li et al. (18), and Orgeta et al. (19) have all demonstrated the effectiveness of cognitive interventions in enhancing memory, attention, executive function, and problem-solving skills, resulting in overall improvements in cognitive performance and quality of life.
Additionally, these interventions can provide valuable strategies for caregivers to manage challenging behaviors and enhance communication with individuals living with dementia (20,21).
Identifying psychotherapies and psychosocial interventions for people with dementia is of utmost importance.It allows health professionals to stay updated with the latest advancements and ensure that interventions are evidence-based.In addition, health professionals and researchers can build upon existing knowledge and refine their approaches to better address the specific needs of people with dementia.Therefore, this review aims to identify current trends in psychotherapies and psychosocial interventions for individuals with dementia.

Methods
This scoping review was drawn based on the framework outlined by Arksey and O'Malley (22) and subsequently expanded upon by Levac et al. (23).In addition, we adhered to the checklist provided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) (24).

Search methods
The research question that guides the review is: What are the current trends in psychotherapies and psychosocial interventions for individuals with dementia?
We developed a search strategy to uncover pertinent literature based on the 'Population-Concept-Context (PCC)' mnemonic.The PCC served as the basis for determining the criteria for inclusion and exclusion (Table 1 The final search was done on June 16, 2023.

Study selection
Duplicated identification was identified, individually reviewed, and removed by CV using Rayyan -AI-Powered Tool for Systematic Literature Reviews.The same researcher performed the screening of manuscript titles to determine potential relevance.CV and SF performed the abstract screening independently, after which they reviewed full-text articles concerning the eligibility criteria.Any discrepancies were settled via discussion and consensus between the reviewers and the involvement of a senior reviewer (JBF) if required.

Data extraction
A data extraction form was developed and used by CV and JBF to collect relevant data from the included studies.For each review, the following data were extracted: study characteristics (e.g., authors, publication year, study design, aim) and intervention details (e.g., type of intervention, duration, frequency, and length).

Data synthesis and analysis
The extracted data were analyzed to identify the current trends in psychotherapies and psychosocial interventions for individuals with dementia.The characteristics and key findings of the included studies were summarized.Based on the guidelines proposed by Braun et al. (25), we conducted a data-driven thematic analysis to identify interventions used in people with dementia.Patterns and consistencies in the reported outcomes across the studies were explored.No statistical analysis or meta-analyses were possible due to significant heterogeneity observed among the included studies, including variations in intervention types, timing of sessions, and settings.Therefore, the findings were extracted and reported systematically.

Results
After a comprehensive search in multiple databases, we initially identified 1409 studies.After the duplicate removal, 1108 studies remained, of which 1089 were excluded based on titles and abstracts.Ultimately, 19 publications were read in full text, and 16 studies that met the eligibility criteria were included in this review.Figure 1 illustrates the selection process.
A list of included randomized controlled trials is shown in Table 2.
Data analysis unveiled a range of psychotherapies and psychosocial interventions for people with dementia.These rehabilitation interventions have been categorized into eight distinct categories.

Computerized game-based cognitive training
Several studies have explored the effectiveness of computerized game-based cognitive training in enhancing cognitive function in individuals with varying degrees of cognitive impairment (30,31,34,36,41).While these studies share the approach of using computerized games to stimulate cognitive abilities, they differ in terms of methodology, intervention strategies, and outcomes.
A study by Han et

Population
• Individuals diagnosed with dementia; • Individuals with mild cognitive impairment or greater; • Adults ≥ 18 years old.
• Other health conditions besides dementia; • Individuals without cognitive impairment or with subjective cognitive impairment; • Participants < 18 years old.

Concept
• Studies that explore psychotherapies and psychosocial interventions.
There are no limitations on the intervention type, provided it aimed to enhance or prevent cognitive dysfunction.
•  (Continued) PRISMA flow chart for study selection.

minutes Weekly sessions
Twelve weeks

• Reminiscence therapy
The intervention group engaged in reminiscence through a life review, reflecting on their memory issues.Notably, there was no confusion regarding the chronological order of events in their autobiographical memories.youth, fostering a collective exploration of past experiences.This approach was complemented by integrating visual aids, including pictures and relevant items, to deepen sensory connections and enrich the reminiscence therapy experience.Similarly, Amieva et al. adopted a group-based approach but introduced a structured program for reminiscence therapy.Their tailored program focused on diverse personal themes, spanning schooldays, birthdays, weddings, working life, and holidays.By delving into these distinct life themes, participants were guided to evoke memories associated with specific events, potentially enhancing cognitive engagement through an organized and targeted strategy.

Compensatory and restorative strategies
Greenaway et al. (38) introduced a compact Memory Support System featuring a two-page per day calendar and a note-taking system tailored to conveniently fit within a man's breast pocket or a woman's purse.This system was devised to offer a practical means of organizing and retaining daily information, enhancing memory recall and daily functioning.
Conversely, Hindle et al. ( 27) took a broader approach by incorporating strategies to manage cognitive difficulties, practical situations, and anxiety symptoms.These strategies encompassed the utilization of compensatory tools such as calendars, diaries, and reminders.Additionally, they incorporated restorative techniques like mnemonic devices and spaced retrieval to bolster the retention of new information and improve recall.Taking a unique perspective on Memory Training, Kim (37) introduced an innovative dementia partner program.This one-onone approach was facilitated via telephone and focused on engaging participants in discussions about news, sharing daily routines, and planning for upcoming days or weeks.

Memory and attention training
In addition to these studies, Juaŕez-Cedillo et al. (40) contributed a multi-component cognitive stimulation program encompassing cognitive aspects like paying attention and maintaining orientation.

Calculation training
Peng et al. (35) employed a Calculation Training strategy involving two straightforward questions and one simple application question for calculation within each intervention session.
Similarly, Amieva et al. (26) developed a program designed to engage various cognitive functions and activities of daily life.Their approach included Calculation Training through tasks such as money counting to improve domestic financial handling.Kim (37) introduced a distinctive dementia partner program that utilized telephone interactions.This program featured tailored cognition items, including calculation checking for specific weekdays, counting numbers in reverse, related word listing games, and pair word telling.computerized game-based motor-cognitive training on an interactive balance platform.

Counseling
In the context of counseling interventions, several studies have employed distinct strategies to address various aspects of health and well-being.Shimada et al. (33) implemented a counseling approach in which instructors educated participants on aging, nutrition, oral care, frailty, and urinary incontinence.The participants also received informative pamphlets on these subjects throughout the study period.
Kim (37) utilized telephone counseling, covering a range of items, including physical self-monitoring, stress intervention, health promotion, mental self-monitoring, nutrition and diet, social competence, challenges in the community, and monitoring physical and mental changes.This comprehensive approach aimed to provide holistic guidance to individuals.
Juaŕez-Cedillo et al. (40) employed counseling to foster personal interaction, boost self-esteem, and enhance personal security.Their approach aimed to address psychological and emotional well-being, further enriching the scope of counseling interventions.
Clare et al. (28) employed counseling to assist participants in defining and achieving up to three rehabilitation goals through a problem-solving approach.They also addressed emotional and motivational challenges by applying emotion regulation and behavioral activation strategies as necessary.

Personalized goal attainment
Hindle et al. (27) introduced a Goal-Oriented Cognitive Rehabilitation program.This intervention embraced evidencebased techniques to guide participants in pursuing agreed-upon goals.The program was structured to align with each participant's objectives, promoting a targeted and personalized approach to cognitive enhancement.
Clare et al. (28) similarly assisted patients in defining rehabilitation goals using a problem-solving approach.Regan et al. (39) offered a personalized intervention called MAXCOG, which honed in on individually significant goals.This approach involved learning names at social events, enhancing medication adherence, and boosting memory for specific activities.Both interventions were tailored to everyone, recognizing and addressing their cognitive needs and challenges.

Discussion
The review evaluated various interventions targeting cognitive enhancement and rehabilitation across multiple categories.A substantial body of literature has examined the effects of computerized game-based cognitive training interventions (30,31,34,36,41).These studies contribute to understanding the versatility  29) study offers a fresh perspective by incorporating technology into dual-task training.While combining motor and cognitive tasks is not new, their use of interactive balance platforms and computerized game-based exercises introduces innovation.This technological integration enhances the approach's complexity and engagement, boosting its potential for motor-cognitive integration and functional outcomes.
The overarching benefit of combined motor and cognitive therapy lies in its potential to reflect the complex cognitive demands of everyday life (42)(43)(44).This approach aligns with emerging theories of brain plasticity, suggesting that the brain's adaptability can be harnessed through integrated interventions (45,46).As cognitive and motor functions intertwine in real-life scenarios, targeting both domains simultaneously in therapy may lead to more efficient and comprehensive improvements in overall functionality.
The review also highlighted compensatory and restorative strategies.These functions include planning, decision-making, organization, problem-solving, and emotional control.Impairments in these areas are characteristic of dementia and significantly affect daily life and independence (47,48).
Beyond direct enhancements in memory, attention, and logical thinking, these training methods offer broader benefits, including increased social engagement, heightened self-esteem, and reduced emotional stress.However, customization to individual needs, considering disease stage, personal preferences, and cognitive capacities, is crucial.

Challenges and considerations
While psychotherapies and psychosocial interventions show promise, challenges must be addressed to ensure their effectiveness and widespread implementation.One challenge is the diverse nature of dementia, requiring tailored interventions to suit individual cognitive profiles and symptom severity (3,49,50).
Although many studies demonstrate short-term positive effects (15,17,51), maintaining cognitive improvements over extended periods remains a concern, necessitating longer follow-up studies.In addition, translating cognitive gains from interventions to realworld situations poses another challenge, requiring ecologically valid training programs (52).
Advancing technology brings new tools for cognitive rehabilitation, potentially revolutionizing the field with engaging, personalized, and accessible interventions (53).Implementation, however, demands multifaceted considerations.
For users, accessibility and usability are paramount, especially for individuals with varying tech familiarity or cognitive impairments.User-friendly, intuitive technology tailored to cognitive abilities preserves user dignity and autonomy, enhancing engagement.
Healthcare professionals play a crucial role, requiring effective technology training.Access to progress tracking ensures effective implementation, necessitating seamless technology integration into healthcare systems.
Economically, evaluating the cost-effectiveness of technologybased interventions is vital.Balancing upfront costs with long-term benefits like improved cognition and enhanced quality of life guides resource allocation.
Ensuring affordability and equity for individuals, families, and healthcare systems is vital, making technology-based interventions accessible regardless of socioeconomic status.

Strengths and limitations
Peng et al. (35) explored Memory and Attention Training using diverse techniques.Their strategy encompassed a Seven-piece board recovery training to challenge and enhance memory recall.They also employed activities like picture-reading memory exercises and phrase recitation.Additionally, they targeted attention development through color reaction training and Schulte Grid exercises.
Shimada et al. (33) utilized Dual-Task Training by combining aerobic exercise, muscle strength training, and postural balance retraining with cognitive tasks.As previously mentioned, Lemke et al. (29) also incorporated Dual-Task Training.However, their approach involved Compensatory strategies, supported by Greenaway et al. (38) and Hindle et al. (27), offer practical solutions by using external aids to navigate cognitive challenges.Memory support systems, calendars, and reminders assist in organizing thoughts and managing tasks.In contrast, as emphasized by Hindle et al. (27), restorative strategies aim to enhance cognitive function through targeted training and interventions.Cognitive exercises, problemsolving techniques, and memory training work to regain lost cognitive abilities and enhance cognitive reserves.Training executive functions in individuals with dementia through interventions like Memory and Attention Training and Calculation Training is profoundly significant, improving their quality of life and potentially slowing symptom progression.
This review's key strength lies in its focus on experimental studies, allowing for a precise exploration of current trends in psychotherapies and psychosocial interventions for individuals with dementia.This review offers valuable insights into promising cognitive training and rehabilitation approaches by explicitly pinpointing interventions subjected to rigorous experimental scrutiny.The comprehensive overview of these interventions facilitates a deep comprehension of the techniques and methodologies employed, simplifying their replication in other settings.Nevertheless, certain limitations do exist in this research.Not all studies provide exhaustive descriptions of interventions, potentially hindering their replication by other professionals.By exclusively focusing on experimental studies, there is a risk of overlooking valuable insights from non-experimental studies, which could enrich the overall comprehension of cognitive training and rehabilitation interventions.Additionally, limiting the search to Scopus and EBSCOhost research platforms might have excluded pertinent studies from alternative sources.Furthermore, specific criteria, such as excluding non-English, Portuguese, and Spanish papers, could introduce biases by omitting relevant literature.Finally, by following the framework outlined by Arksey and O'Malley, this scoping review does not include the assessment of study quality as a component of the scoping process.Recognizing these limitations is crucial to maintaining a balanced interpretation of the findings and encouraging further research that transcends this review's scope.5 Conclusion This review facilitated the synthesis of evidence on psychotherapies and psychosocial interventions for individuals with dementia and captured current trends encompassing various approaches, ranging from computerized game-based cognitive training and reminiscence therapy to compensatory and restorative strategies, memory and attention training, calculation training, dual-task training, counseling, and personalized goal attainment.Dementia poses a significant global health challenge with farreaching consequences for individuals, families, and society.Cognitive training and rehabilitation interventions are vital in enhancing cognitive functioning, independence, and quality of life for individuals with dementia.Continued research, innovation, and collaboration across disciplines are necessary to develop and refine interventions that can make a meaningful difference in the lives of individuals with dementia.

TABLE 2
Data extraction and synthesis.

TABLE 2 Continued
of computerized game-based cognitive training interventions.The consistent findings across these studies suggest that technologydriven interventions can engage participants while targeting a range of cognitive functions.The successful integration of technology into cognitive rehabilitation strategies opens avenues for more personalized, engaging, and adaptable interventions tailored to diverse populations, from mild cognitive impairment to stroke survivors.Nakamura et al. (32) and Amieva et al. (26) provided insight into the use of reminiscence therapy.Group-based reminiscence therapy, supported by visual aids and tailored themes, emerged as a valuable approach for engaging individuals in recalling and sharing past experiences.This therapy promotes memory recall and offers potential benefits for emotional well-being and social interaction.Studies by Peng et al. (35), Juaŕez-Cedillo et al. (40), and Kim (37) highlighted the versatility of memory training interventions.Approaches varied from seven-piece board recovery training, tailored tasks at different difficulty levels, to unique dementia partner programs via telephone.These interventions emphasize the potential to enhance memory through various techniques, ranging from challenging exercises to personalized interactions.Lemke et al. (29) and Shimada et al. (33) have explored integrating motor and cognitive therapy in dual-task training interventions.This method combines physical exercises with cognitive tasks, showing a synergistic effect that enhances motorcognitive integration and overall performance.Lemke et al. ( (39)le et al. (27), Clare et al.(28), and Regan et al.(39)underscored tailored interventions focusing on individual goals, aligning cognitive rehabilitation with personally meaningful objectives to enhance motivation and outcomes.The review's findings highlight diverse interventions, emphasizing the absence of a universal approach to enhance cognitive function and participation restriction.In the broader context, a comprehensive strategy is crucial to meet the diverse needs of those with cognitive impairments and participation restriction.No single intervention is a panacea.Instead, cognitive rehabilitation emerges from the synergy of various interventions, addressing specific cognitive challenges.By embracing various strategies, a holistic program can be designed to accommodate each patient's unique strengths and weaknesses.Ultimately, a well-rounded rehabilitation program for people with dementia acknowledges the multifaceted nature of cognitive impairments.By offering personalized interventions, professionals can optimize benefits for individuals, empowering them to enhance cognitive abilities, regain independence, and elevate overall quality of life.