Orgeta Vasiliki, McDonald Kathryn R, Poliakoff Ellen, Hindle John Vincent, Clare Linda, Leroi Iracema
University College London, Division of Psychiatry, 6th Floor, Maple House,, 149 Tottenham Court Road,, London, UK, W1T 7NF.
University of Manchester, Division of Neuroscience and Experimental Psychology, School of Biological Sciences, Faculty of Biology, Medicine and Health, 3.306, Jean McFarlane Building, Oxford Road, Manchester, UK, M13 9PL.
Cochrane Database Syst Rev. 2020 Feb 26;2(2):CD011961. doi: 10.1002/14651858.CD011961.pub2.
Approximately 60% to 80% of people with Parkinson's disease (PD) experience cognitive impairment that impacts on their quality of life. Cognitive decline is a core feature of the disease and can often present before the onset of motor symptoms. Cognitive training may be a useful non-pharmacological intervention that could help to maintain or improve cognition and quality of life for people with PD dementia (PDD) or PD-related mild cognitive impairment (PD-MCI).
To determine whether cognitive training (targeting single or multiple domains) improves cognition in people with PDD and PD-MCI or other clearly defined forms of cognitive impairment in people with PD.
We searched the Cochrane Dementia and Cognitive Improvement Group Trials Register (8 August 2019), the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL, and PsycINFO. We searched reference lists and trial registers, searched relevant reviews in the area and conference proceedings. We also contacted experts for clarifications on data and ongoing trials.
We included randomised controlled trials where the participants had PDD or PD-MCI, and where the intervention was intended to train general or specific areas of cognitive function, targeting either a single domain or multiple domains of cognition, and was compared to a control condition. Multicomponent interventions that also included motor or other elements were considered eligible.
Two review authors independently screened titles, abstracts, and full-text articles for inclusion in the review. Two review authors also independently undertook extraction of data and assessment of methodological quality. We used GRADE methods to assess the overall quality of the evidence.
Seven studies with a total of 225 participants met the inclusion criteria for this review. All seven studies compared the effects of a cognitive training intervention to a control intervention at the end of treatment periods lasting four to eight weeks. Six studies included people with PD living in the community. These six studies recruited people with single-domain (executive) or multiple-domain mild cognitive impairment in PD. Four of these studies identified participants with MCI using established diagnostic criteria, and two included both people with PD-MCI and people with PD who were not cognitively impaired. One study recruited people with a diagnosis of PD dementia who were living in long-term care settings. The cognitive training intervention in three studies targeted a single cognitive domain, whilst in four studies multiple domains of cognitive function were targeted. The comparison groups either received no intervention or took part in recreational activities (sports, music, arts), speech or language exercises, computerised motor therapy, or motor rehabilitation combined with recreational activity. We found no clear evidence that cognitive training improved global cognition. Although cognitive training was associated with higher scores on global cognition at the end of treatment, the result was imprecise and not statistically significant (6 trials, 178 participants, standardised mean difference (SMD) 0.28, 95% confidence interval (CI) -0.03 to 0.59; low-certainty evidence). There was no evidence of a difference at the end of treatment between cognitive training and control interventions on executive function (5 trials, 112 participants; SMD 0.10, 95% CI -0.28 to 0.48; low-certainty evidence) or visual processing (3 trials, 64 participants; SMD 0.30, 95% CI -0.21 to 0.81; low-certainty evidence). The evidence favoured the cognitive training group on attention (5 trials, 160 participants; SMD 0.36, 95% CI 0.03 to 0.68; low-certainty evidence) and verbal memory (5 trials, 160 participants; SMD 0.37, 95% CI 0.04 to 0.69; low-certainty evidence), but these effects were less certain in sensitivity analyses that excluded a study in which only a minority of the sample were cognitively impaired. There was no evidence of differences between treatment and control groups in activities of daily living (3 trials, 67 participants; SMD 0.03, 95% CI -0.47 to 0.53; low-certainty evidence) or quality of life (5 trials, 147 participants; SMD -0.01, 95% CI -0.35 to 0.33; low-certainty evidence). There was very little information on adverse events. We considered the certainty of the evidence for all outcomes to be low due to risk of bias in the included studies and imprecision of the results. We identified six ongoing trials recruiting participants with PD-MCI, but no ongoing trials of cognitive training for people with PDD.
AUTHORS' CONCLUSIONS: This review found no evidence that people with PD-MCI or PDD who receive cognitive training for four to eight weeks experience any important cognitive improvements at the end of training. However, this conclusion was based on a small number of studies with few participants, limitations of study design and execution, and imprecise results. There is a need for more robust, adequately powered studies of cognitive training before conclusions can be drawn about the effectiveness of cognitive training for people with PDD and PD-MCI. Studies should use formal criteria to diagnose cognitive impairments, and there is a particular need for more studies testing the efficacy of cognitive training in people with PDD.
约60%至80%的帕金森病（PD）患者存在认知障碍，这会影响他们的生活质量。认知衰退是该疾病的一个核心特征，且常常在运动症状出现之前就已存在。认知训练可能是一种有用的非药物干预措施，有助于维持或改善帕金森病痴呆（PDD）或帕金森病相关轻度认知障碍（PD-MCI）患者的认知及生活质量。
确定认知训练（针对单一或多个领域）是否能改善PDD和PD-MCI患者或帕金森病患者其他明确界定的认知障碍形式的认知功能。
我们检索了Cochrane痴呆与认知改善小组试验注册库（2019年8月8日）、Cochrane对照试验中央注册库（CENTRAL）、MEDLINE、Embase、CINAHL和PsycINFO。我们检索了参考文献列表和试验注册库，检索了该领域的相关综述及会议论文集。我们还联系了专家以澄清数据和正在进行的试验情况。
我们纳入了随机对照试验，试验参与者为PDD或PD-MCI患者，干预措施旨在训练认知功能的一般或特定领域，针对单一认知领域或多个认知领域，并与对照条件进行比较。包含运动或其他元素的多成分干预措施被视为符合条件。
两位综述作者独立筛选标题、摘要和全文文章以纳入综述。两位综述作者还独立进行数据提取和方法学质量评估。我们使用GRADE方法评估证据的总体质量。
七项研究共225名参与者符合本综述的纳入标准。所有七项研究在为期四至八周的治疗期结束时，比较了认知训练干预与对照干预的效果。六项研究纳入了社区中的帕金森病患者。这六项研究招募了患有单一领域（执行功能）或多领域轻度认知障碍的帕金森病患者。其中四项研究使用既定诊断标准识别出MCI参与者，两项研究纳入了PD-MCI患者和无认知障碍的帕金森病患者。一项研究招募了居住在长期护理机构中的帕金森病痴呆患者。三项研究中的认知训练干预针对单一认知领域，而四项研究针对多个认知功能领域。对照组要么未接受干预，要么参加娱乐活动（体育、音乐、艺术）、言语或语言练习、计算机化运动疗法，或运动康复与娱乐活动相结合。我们没有发现明确证据表明认知训练能改善整体认知。尽管认知训练在治疗结束时与整体认知的较高分数相关，但结果不精确且无统计学意义（6项试验，178名参与者，标准化均数差（SMD）0.28，95%置信区间（CI）-0.03至0.59；低确定性证据）。没有证据表明治疗结束时认知训练与对照干预在执行功能（5项试验，112名参与者；SMD 0.10，95% CI -0.28至0.48；低确定性证据）或视觉处理（3项试验，64名参与者；SMD 0.30，95% CI -0.21至0.81；低确定性证据）方面存在差异。证据支持认知训练组在注意力（5项试验，160名参与者；SMD 0.36，95% CI 0.03至0.68；低确定性证据）和言语记忆（5项试验，160名参与者；SMD 0.37，95% CI 0.04至0.69；低确定性证据）方面的效果，但在排除一项只有少数样本存在认知障碍的研究的敏感性分析中，这些效果的确定性较低。没有证据表明治疗组与对照组在日常生活活动（3项试验，67名参与者；SMD 0.03，95% CI -0.47至0.53；低确定性证据）或生活质量（5项试验，147名参与者；SMD -0.01，95% CI -0.35至0.33；低确定性证据）方面存在差异。关于不良事件的信息非常少。由于纳入研究存在偏倚风险且结果不精确，我们认为所有结局的证据确定性都很低。我们确定有六项正在进行的试验招募PD-MCI患者，但没有针对PDD患者的认知训练正在进行的试验。
本综述未发现证据表明接受四至八周认知训练的PD-MCI或PDD患者在训练结束时出现任何重要的认知改善。然而，这一结论基于少数研究、参与者数量少、研究设计和实施的局限性以及不精确的结果。在得出关于认知训练对PDD和PD-MCI患者有效性的结论之前，需要进行更有力、样本量充足的认知训练研究。研究应使用正式标准诊断认知障碍，尤其需要更多研究来测试认知训练对PDD患者的疗效。
