Improved social interaction and increased anterior cingulate metabolism after group reminiscence with reality orientation approach for vascular dementia

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Abstract

A group reminiscence approach (GRA) with reality orientation (RO) is widely used as a psychosocial intervention for dementia. Since clinical effectiveness was reported for the intervention, interest has been directed toward areas of the neuronal network that might be being stimulated. We hypothesized that the frontal lobe associated with social interaction was being stimulated. To test this hypothesis, we studied 24 patients with vascular dementia. In addition to conventional care, a 1-h session of GRA with RO was provided once a week for 3 months in the GRA-RO arm (n = 12). Only supportive care was provided in the control arm (n = 12). Before and after the interventions, cognitive function, depressive state, and social activities were assessed. Since glucose metabolism is associated with brain function, cerebral glucose metabolism was measured by positron emission tomography (PET). Regarding behavioral improvement, 10 patients in the GRA-RO arm showed improvement compared with only two patients in the control arm, a significant difference. PET demonstrated that metabolism in the anterior cingulate was increased in the GRA-RO arm, whereas no significant changes were observed in the control arm. These results suggest that GRA-RO stimulates the anterior cingulate and has a positive effect on social interaction.

Introduction

Behavioral problems are recognized as important clinical features of dementia. These problems affect patients' quality of life, and have been associated with increased caregiver burden. For vascular dementia (VaD), social inactivity or apathy is one of the major problems especially for small vessel disease (Staekenborg et al., 2009), and thus psychosocial intervention as well as drug treatments may be promoted.

Regarding psychosocial interventions, the reminiscence approach is usually performed for older adults based on the concept of “life review as a naturally occurring, universal mental process” (Butler, 1963). It consists of recollections and discussions of past events in one's life with the aid of materials that invoke memories, and it is classified into two methods: individual reminiscence and group reminiscence approach (GRA) (Wang, 2007). Reality orientation (RO) (Taulbee and Holsom, 1966) is another intervention aimed for reinforced recognition of orientation. Some researchers reported (Baines et al., 1987, Goldwasser et al., 1987, Tadaka et al., 2000, Tadaka and Kanagawa, 2004, Akanuma et al., 2006) that GRA with RO exhibited synergistic effects, and a combined approach has been widely practiced.

Several GRA studies disclosed that feelings of self-achievement and emotional stability were enhanced, although there were no significant changes in cognitive or depression scores (Haslam et al., 2010). Social activity was also enhanced (Huang et al., 2009, Wang et al., 2009), self-esteem increased, and behavioral disturbance decreased (Yasuda et al., 2009). As a preliminary study, we previously used GRA with RO fin seven institutionalized patients with VaD and found that social interaction improved despite no cognitive changes (Akanuma et al., 2006). The improvement was not limited to the duration of the GRA with RO but was also observed in the patients' daily lives. Since some clinical effectiveness of GRA with RO was reported, areas of the neuronal network were presumed to have been stimulated. Although functional neuroimaging has been applied to study pharmacotherapy or even rehabilitation approaches, no such investigations have been performed for psychosocial interventions.

Recently Peres and Nasello (2008) presented a review on psychotherapy and neuroscience. Current neuroscience with its integrative approach is bringing together research from molecular through cognitive levels, and psychotherapy has benefited from these findings. Functional neuroimaging studies may make specific and more far-reaching contributions in this respect, since cerebral dynamics may be observed. Methods such as positron emission tomography (PET) have been able to evaluate the neural correlates involved in psychotherapy. Researchers have found that psychotherapy has the potential to modify dysfunctional neural circuits associated with these disorders.

Since the effect of GRA with RO may not be limited to the intervention time but may also carry over to the patients' daily lives, we hypothesized that some brain areas associated with social interaction, such as the frontal lobe, might be stimulated for a long time. Glucose metabolism (CMRglc) as shown by PET is associated with brain function; thus, we performed a PET study to evaluate brain metabolism in a resting condition before and after the intervention and investigated the effect of psychosocial intervention on daily lives for VaD.

Section snippets

Institutional facility

The study was performed in a geriatric nursing home in Nakada, which is located in a rural area of northern Japan. It is a 150-bed institution that includes a 40-bed special care unit for dementia in which medication can be administered. All the patients in the study were institutionalized.

Patients

We studied 24 patients with VaD that met the following inclusion criteria: 1) the diagnostic criteria of ischemic VaD of the ADDTC (Chui et al., 1992) with reference to CT or MRI findings; 2) they had been

Chi-square tests

After the intervention, one patient in the GRA-RO arm (n = 12) showed cognitive improvement as shown by a 3-point increase in the MMSE score, as did two patients in the control arm (n = 12). No group differences were noted by the chi-square test (1/12 vs 2/12).

For the behavioral improvement as shown by the Social/Communication and Activities (SA) subscales of BRSE, 10 patients in the GRA-RO arm (n = 12) improved, so did only two patients in the control arm (n = 12). There was a significant difference

Discussion

Since there were no remarkable changes of cognitive or depressive scores after the GRA with RO intervention, the improved social interaction was not simply attributed to such functions. Rather, social interaction and activity may be stimulated.

We previously performed such an intervention in patients with Alzheimer's disease (Meguro et al., 2008): as the characteristics of the disease, their speech abilities were relatively spared and they could perform superficial conversation in a group.

Conflict of interests

None.

Financial disclosure

None.

Acknowledgements

The authors thank all the staffs in Nursing Home Nakada, especially for Mr. Kentaro Chiba and Mr. Daisuke Nakashio. The technical assistance of PET examination by Ms T. Ito was also appreciated.

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