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Cognitive stimulation: effect on caregivers Geriatr Gerontol Aging. 2019;13(1):39-49 40 INTRODUCTION Dementia is a neurocognitive disorder characterized by overall and progressive deterioration of cognitive abilities leading to progressive functional loss.1,2 Managing dementia in older adults may be particularly challenging for caregivers, as they are exposed to higher care demands and increasingly stressful situations.3,4 Thus, there is a pressing need for interventions seeking to reduce the impacts of the activity on caregivers’ health status.5 The current literature describes non-pharmacological interventions aiming to increase care-related skills and improve caregivers’ quality of life (QoL), including psychosocial and psychoeducational groups.6 Other interventions, in turn, aim to decelerate the process of cognitive and functional loss in older adults with dementia and, as a result, contribute to reducing caregivers’ burden,4,7 such as cognitive stimulation (CS). CS is defined as a series of activities and techniques whose overall objective is to improve cognitive and social functioning in older adults with dementia.8-10 The intervention has been extensively studied8-10, and there is robust evidence supporting that CS leads to cognitive improvement, including attention, memory, orientation, language, and overall cognitive function, as well as improvement related to self-reported well-being, QoL, communication, and social interaction in older adults with dementia.10 However, confirmation of CS benefits to the health of caregivers of older adults requires further investigation. Understanding the health outcomes of CS in caregivers of older adults with dementia has become relevant. Such knowledge may help planning interventions that provide benefits both to older adults with dementia and to their caregivers.7 Therefore, this systematic literature review aimed to identify and evaluate the effect of CS interventions on the health of caregivers of older adults with dementia. METHOD Search strategy This systematic review was conducted in accordance with Preferred Reporting Items for Systematic Review and Metaanalysis Protocols (PRISMA) guidelines.11 Five databases — Latin American and Caribbean Health Science Literature Database (LILACS), Physiotherapy Evidence Database (PEDro), PsycINFO, PubMed, and Scientific Electronic Library Online (SciELO) — were searched using the following terms: “demência” OR “dementia” AND “estimulação cognitiva” OR “cognitive stimulation” OR “estimulación cognitive.” Eligibility criteria Only randomized controlled trials in which CS targeted older people (aged 60 years or above) diagnosed with dementia and outcomes were measured in caregivers were included. Interventions should have been delivered individually or in groups by a professional or by a caregiver. Articles in Portuguese, English, or Spanish published from January 2007 to April 2018 were considered eligible. Studies were excluded if CS was conducted concomitantly to a support group for caregivers of older adults with dementia. Study selection Using the eligibility criteria, two researchers searched the databases independently, in May 2018. They selected articles for this review after screening titles and abstracts or full texts. There was no disagreement between the researchers regarding eligible articles. The results from different databases were cross-checked and duplicate studies were removed. Quality assessment All articles meeting the inclusion criteria were submitted to the PEDro scale, which rates the methodological quality of trial reports using 11 criteria for internal validity.12 Because item 1 in the PEDro scale refers to external validity, it is not used to calculate the final score. Thus, the maximum quality score is 10. RESULTS The search yielded 395 articles, then 95 were excluded for being duplicate, resulting in 300 articles which were evaluated for eligibility. Of those, 124 articles were excluded after title and abstract screening (78 were review articles; 21 were pilot studies; 16 were editorials or letters to the editor; eight were written in languages other than those of the inclusion criteria; and one study conducted CS concomitantly to a caregiver support group). After full-text screening, 166 articles were excluded (143 did not report CS outcomes in caregivers; 19 were not randomized controlled trials; and four did not recruit older people diagnosed with dementia). Therefore, the final sample consisted of 10 articles included in this systematic review (Figure 1). Quality assessment Most studies included in this systematic review presented moderate or high methodological quality. Eight trials scored 5 or higher in the PEDro scale (Table 1). Pinto TTM, Alencar MA, Arantes PMM, Assis LO Geriatr Gerontol Aging. 2019;13(1):39-49 41 Characteristics of included studies The 10 trials included in this review had sample size ranging from 17 to 261 older adults, recruited from community settings, adult day care centers, long-term care facilities, sanatorium, clinics, and geriatric or teaching hospitals. They were diagnosed with various types of dementia (Table 2). The criteria for diagnosing dementia varied among the studies. The most commonly used criteria were the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV ),13-15 the National Institute of Neurological and Communicative Disorders and StrokeAlzheimer’s Disease and Related Disorders Association Work Group (NINCDS-ADRDA),16-18 and the International Classification of Diseases, 10th Revision (CID-10).19 The Mini-Mental State Examination (MMSE)13,14,17-20 and the Global Deterioration Scale (GDS) were used for staging dementia.21 Seven studies included older adults with mild to moderate dementia,13-15,17,18,20,21 one included older adults transitioning to moderate stage,16 one included older adults with moderate dementia,19 and one did not specify dementia stage.7 The characteristics of the selected trials are shown in Table 2. Characteristics of interventions The characteristics of the intervention programs varied greatly in relation to number of sessions (8 to 144 meetings), duration (30 to 180 minutes), and frequency of care (1 to 5 times a week). Most CS interventions were conducted in SciELO: Scientific Electronic Library Online; PEDro: Physiotherapy Evidence Database. Figure 1 Flow of information. PubMd n = 237 PsycINFO n = 132 SciELO n = 20 PEDro n = 6 Total n = 395

Estimulação cognitiva em idosos com demência: qual o impacto na saúde de seus cuidadores?