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Treatment of Alzheimer's Disease

To the Editor: We read with interest the practice guideline for the treatment of Alzheimer's disease. We appreciated very much the effort to gather a large and fragmented body of knowledge—from diagnosis to treatment to long-term care issues—and to clearly identify the levels of clinical confidence for each practice recommendation.

We disagree, however, with the conclusion drawn regarding the "specific psychotherapies and other psychosocial treatments." The authors state: "Cognition-oriented treatments, such as reality orientation, cognitive retraining, and skills training, are focused on specific cognitive deficits, are unlikely to be beneficial, and have been associated with frustration in some patients." While Alzheimer's patients fail to benefit from a variety of environmental and cognitive rehabilitative interventions carried out in order to improve cognitive functions, some interesting exceptions to this negative pattern have been demonstrated, mainly within the realm of reality orientation (1, 2). Recently, the efficacy of rehabilitative programs more focused on skills that are relatively preserved in the mild stages of Alzheimer's disease, such as procedural memory, have also been demonstrated (3-5).

The authors of the guideline seem to overstate the adverse effects while understating the body of evidence suggesting the effectiveness, albeit moderate, of cognitive and procedural memory rehabilitative interventions that could be recommended with moderate clinical confidence.

REFERENCES

1. Backman L: Memory training and memory improvement in Alzheimer's disease: rules and exceptions. Acta Neurol Scand 1992; 139(suppl):84–89
2. Zanetti O, Frisoni GB, De Leo D, Dello Buono M, Bianchetti A, Trabucchi M: Reality orientation therapy in Alzheimer's disease: useful or not? A controlled study. Alzheimer Dis Assoc Disord 1995; 9:132–138[Medline]
3. Zanetti O, Binetti G, Magni E, Rozzini L, Bianchetti A, Trabucchi M: Procedural memory stimulation in Alzheimer's disease: impact of a training programme. Acta Neurol Scand 1997; 95(3):152–157
4. Josephsson S, Backman L, Borell L, Bernspang B, Nygard L, Ronnberg L: Supporting everyday activities in dementia: an intervention study. J Geriatr Psychiatr 1993; 8:395–400
5. Camp CJ, Foss JW, Stevens AB, Reichard CC, McKitrick LA, O'Hanlon AM: Memory training in normal and demented elderly populations: the E-I-E-I-O model. Exp Aging Res 1993; 19:277–290[Medline]

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