High-quality, rigorous, large-scale evaluations of psychosocial interventions in dementia care always represent a valuable addition to the literature. It is good, then, to see a randomized controlled trial of the CORDIAL program, originally developed in Germany (Kurz et al., Reference Kurz2012), and adapted, developed, and evaluated in Norway (Tonga et al., Reference Tonga, Benth, Arnevik, Werheid, Korsnes and Ulstein2020). As the 2011 INTERDEM Manifesto (Moniz-Cook et al., Reference Moniz-Cook, Vernooij-Dassen, Woods, Orrell and Network.2011) stated “Research is needed to translate and implement what (has) been achieved in one country to the cultures and contexts of other nations”. Psychosocial interventions are strongly influenced by culture and context, and there is no guarantee that an intervention that is successful in one country will be similarly effective elsewhere (Vernooij-Dassen et al., Reference Vernooij-Dassen2019). The replication of the original findings from Germany of an impact of the CORDIAL program on depressive symptoms (Werheid et al., Reference Werheid, Köhncke, Ziegler and Kurz2015) and its extension to male as well as female participants is accordingly especially welcome.
As with all good research, we are left, of course, with a number of further directions to pursue relating both to the CORDIAL program and to the current Norwegian evaluation.
Shifting aims and outcomes
In the current study, CORDIAL is presented as an intervention for depressive symptoms in people with cognitive impairment. However, the program was originally developed to support “the management of day-to-day problems” (Kurz et al., Reference Kurz2012), with an instrument assessing activities of daily living (ADLs) as the primary outcome measure. The effects on depressive symptoms (in female participants only) were a secondary finding, although clearly one worth pursuing. The insensitivity of ADL measures is cited by Kurz et al. (Reference Kurz2012) as one reason for the lack of change on their primary outcome and does raise the question of what are the appropriate outcome measures for such studies. The approach taken by Clare et al. (Reference Clare2019) in their trial of cognitive rehabilitation has much to commend it. They used an individualized goal-setting approach, where participants set their own goals and rated their performance on them before and after the intervention. Such a personalized approach recognizes the heterogeneity among people with dementia (Vernooij-Dassen et al., Reference Vernooij-Dassen2019) and avoids the constraints of the standardized measures. In the current study, an instrumental ADL scale was included but does not feature in the reporting of results, with their primary focus on the antidepressant properties of CORDIAL.
The target population
Depressive symptoms are common in people with dementia and have been shown to relate to the person’s quality of life (Woods et al., Reference Woods2014) as well as having an effect on caregivers. Tonga et al. (Reference Tonga, Benth, Arnevik, Werheid, Korsnes and Ulstein2020) have re-purposed CORDIAL, making adaptations to the emphasis and order of modules so that it can be seen to target depressive symptoms more directly. There is clearly a need for a psychosocial intervention for the large number of people with dementia who also have significant depressive symptoms; medications are limited in their effects, and the evidence base for the effects of psychosocial interventions, while promising is not yet well established (Orgeta et al., Reference Orgeta, Qazi, Spector and Orrell2015). Cognitive-behavioral approaches have been described for some years (Scholey and Woods, Reference Scholey and Woods2003), but evaluations remain few and largely small scale (Tay et al., Reference Tay, Subramaniam and Oei2019). If we are to have evidence-based interventions for people with co-morbid dementia and depression, we will at some point need trials which purposively recruit people who meet these criteria. It should be noted that a diagnosis of depression or significant depressive symptoms was not required for inclusion by Tonga et al. The mean score of the intervention group on the depression scale used was in the “no depression” range at the outset. Interestingly, a third of the participants did report at least “mild depression”, so recruiting such a sample, while perhaps more challenging, would not be impossible. Of course, it can be argued that a mixed sample of people with dementia allows the opportunity to ascertain whether such an intervention prevents depression developing, but such a trial would require a long follow-up period and enumeration of the proportion of participants falling within different levels of the depression classification.
Mix and match?
CORDIAL is described as a multicomponent intervention, combining elements of cognitive behavior therapy (CBT), cognitive rehabilitation, and reminiscence therapy. In any multicomponent approach, questions arise as to what might be the key ingredients and what is the most effective mix including, as Tonga et al. indicated, the best sequence in which to deliver them. One can envisage studies of mechanisms of change will be needed, for example, looking at CORDIAL with and without its reminiscence module.
Multicomponent approaches are by their nature difficult to categorize. At a time when progress in the evidence base increasingly relies on systematic reviews and meta-analyses, can approaches such as CORDIAL add to a wider literature or can it only be analyzed in its own terms? As an author/co-author of several relevant Cochrane Reviews (e.g. Kudlicka et al., Reference Kudlicka, Martyr, Bahar-Fuchs, Woods and Clare2019; Woods et al., Reference Woods, O’Philbin, Farrell, Spector and Orrell2018), I am increasingly aware how difficult it can be to pin down and categorize multicomponent therapeutic approaches. For example, CORDIAL has not been included in reviews of reminiscence therapy, but should it be included in reviews of CBT for depression or of cognitive rehabilitation? Or will we reach a point where such labels will cease to be meaningful as individualization of therapy develops?
Tonga et al. (Reference Tonga, Benth, Arnevik, Werheid, Korsnes and Ulstein2020) make the case that broad, multicomponent approaches are useful because of the heterogeneity of dementia. Equally, it could be argued that the resulting approach risks not having sufficient amounts of any of its components to make a therapeutic difference, and that what is needed is an overall framework within which the right approach can be provided for the individual. As Vernooij-Dassen et al. (Reference Vernooij-Dassen2019) comment, we need to make “progress in relation to what works for whom, when and where” and put paid to the fallacy that “one size fits all”.
Individualized approaches
All three components of the CORDIAL approach lend themselves to a highly individualized approach, with CBT and cognitive rehabilitation benefitting greatly from the scope for setting personal goals and building on individual strengths and resources. Although reminiscence groups are popular, if reminiscence has an effect on depressed mood, it is more likely to be found in individual reminiscence (although not typically in two sessions!) (Woods et al., Reference Woods, O’Philbin, Farrell, Spector and Orrell2018). It is interesting to note that Brueggen et al. (Reference Brueggen2017) reported a small study using CORDIAL in a group setting; reflecting the earlier discussion of CORDIAL not being designed as an intervention for depression, they did not include a measure of depression in their outcomes. Despite a tendency in dementia care to gravitate toward group-based approaches, retaining the individual approach does appear to capture the essence of CORDIAL, although it should be noted that family caregivers also played a key role in the Tonga et al. study, participating in 6 of 11 eleven sessions. These caregivers had remarkably low levels of stress compared with family caregivers in other studies (e.g. Woods et al., Reference Woods2016: Relatives Stress Scale mean 21.8 ± 10.8; Tonga et al., Reference Tonga, Benth, Arnevik, Werheid, Korsnes and Ulstein2020: Relatives Stress Scale mean 12.7 ± 10.4). They may not then be typical of those coming forward for help in a clinical context, and more work may be needed regarding how best to engage dyads of people with dementia and family caregivers to maximize benefits for both parties.
Dementia and mild cognitive impairment (MCI)
In contrast to the other evaluations of the CORDIAL program cited, Tonga et al. (Reference Tonga, Benth, Arnevik, Werheid, Korsnes and Ulstein2020) have not focused exclusively on people with dementia in their sample recruitment. People with amnestic MCI were also included, making up 40% of the overall sample. This may help explain the relatively young age of the sample in comparison with other studies, as well as the aforementioned relatively low stress levels of their family caregivers, many of whom might not have begun to consider themselves as caregivers as such. Of course, depressive symptoms are indeed common in people who are categorized as having MCI (Yates et al., Reference Yates, Clare and Woods2013), but the direction of causality is even less clear in MCI, with the real possibility that at least part of any observed cognitive impairment arises from depressed mood, rather than depressive symptoms being a consequence of cognitive impairment. Again, for the purposes of meta-analyses, pooling data for people with dementia and MCI is problematic; we need effective treatment approaches for people with dementia and people with MCI, but we need to be able to distinguish between them. Reporting results separately for different diagnostic groups would reduce this difficulty, of course.
The CORDIAL approach emerges as a promising psychosocial intervention approach, serving to reinforce the potential, and largely untapped, utility of CBT in this context, here in combination with aspects of cognitive rehabilitation. Focusing further on its potential to reduce depressive symptoms in those people with dementia (and MCI) who have low mood and other indicators of depression would be a valuable way forward. More individualized outcome assessment might assist in the identification of other outcomes, including for those without depressed mood, but who wish to improve and manage their day-to-day function.
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High-quality, rigorous, large-scale evaluations of psychosocial interventions in dementia care always represent a valuable addition to the literature. It is good, then, to see a randomized controlled trial of the CORDIAL program, originally developed in Germany (Kurz et al., Reference Kurz2012), and adapted, developed, and evaluated in Norway (Tonga et al., Reference Tonga, Benth, Arnevik, Werheid, Korsnes and Ulstein2020). As the 2011 INTERDEM Manifesto (Moniz-Cook et al., Reference Moniz-Cook, Vernooij-Dassen, Woods, Orrell and Network.2011) stated “Research is needed to translate and implement what (has) been achieved in one country to the cultures and contexts of other nations”. Psychosocial interventions are strongly influenced by culture and context, and there is no guarantee that an intervention that is successful in one country will be similarly effective elsewhere (Vernooij-Dassen et al., Reference Vernooij-Dassen2019). The replication of the original findings from Germany of an impact of the CORDIAL program on depressive symptoms (Werheid et al., Reference Werheid, Köhncke, Ziegler and Kurz2015) and its extension to male as well as female participants is accordingly especially welcome.
As with all good research, we are left, of course, with a number of further directions to pursue relating both to the CORDIAL program and to the current Norwegian evaluation.
Shifting aims and outcomes
In the current study, CORDIAL is presented as an intervention for depressive symptoms in people with cognitive impairment. However, the program was originally developed to support “the management of day-to-day problems” (Kurz et al., Reference Kurz2012), with an instrument assessing activities of daily living (ADLs) as the primary outcome measure. The effects on depressive symptoms (in female participants only) were a secondary finding, although clearly one worth pursuing. The insensitivity of ADL measures is cited by Kurz et al. (Reference Kurz2012) as one reason for the lack of change on their primary outcome and does raise the question of what are the appropriate outcome measures for such studies. The approach taken by Clare et al. (Reference Clare2019) in their trial of cognitive rehabilitation has much to commend it. They used an individualized goal-setting approach, where participants set their own goals and rated their performance on them before and after the intervention. Such a personalized approach recognizes the heterogeneity among people with dementia (Vernooij-Dassen et al., Reference Vernooij-Dassen2019) and avoids the constraints of the standardized measures. In the current study, an instrumental ADL scale was included but does not feature in the reporting of results, with their primary focus on the antidepressant properties of CORDIAL.
The target population
Depressive symptoms are common in people with dementia and have been shown to relate to the person’s quality of life (Woods et al., Reference Woods2014) as well as having an effect on caregivers. Tonga et al. (Reference Tonga, Benth, Arnevik, Werheid, Korsnes and Ulstein2020) have re-purposed CORDIAL, making adaptations to the emphasis and order of modules so that it can be seen to target depressive symptoms more directly. There is clearly a need for a psychosocial intervention for the large number of people with dementia who also have significant depressive symptoms; medications are limited in their effects, and the evidence base for the effects of psychosocial interventions, while promising is not yet well established (Orgeta et al., Reference Orgeta, Qazi, Spector and Orrell2015). Cognitive-behavioral approaches have been described for some years (Scholey and Woods, Reference Scholey and Woods2003), but evaluations remain few and largely small scale (Tay et al., Reference Tay, Subramaniam and Oei2019). If we are to have evidence-based interventions for people with co-morbid dementia and depression, we will at some point need trials which purposively recruit people who meet these criteria. It should be noted that a diagnosis of depression or significant depressive symptoms was not required for inclusion by Tonga et al. The mean score of the intervention group on the depression scale used was in the “no depression” range at the outset. Interestingly, a third of the participants did report at least “mild depression”, so recruiting such a sample, while perhaps more challenging, would not be impossible. Of course, it can be argued that a mixed sample of people with dementia allows the opportunity to ascertain whether such an intervention prevents depression developing, but such a trial would require a long follow-up period and enumeration of the proportion of participants falling within different levels of the depression classification.
Mix and match?
CORDIAL is described as a multicomponent intervention, combining elements of cognitive behavior therapy (CBT), cognitive rehabilitation, and reminiscence therapy. In any multicomponent approach, questions arise as to what might be the key ingredients and what is the most effective mix including, as Tonga et al. indicated, the best sequence in which to deliver them. One can envisage studies of mechanisms of change will be needed, for example, looking at CORDIAL with and without its reminiscence module.
Multicomponent approaches are by their nature difficult to categorize. At a time when progress in the evidence base increasingly relies on systematic reviews and meta-analyses, can approaches such as CORDIAL add to a wider literature or can it only be analyzed in its own terms? As an author/co-author of several relevant Cochrane Reviews (e.g. Kudlicka et al., Reference Kudlicka, Martyr, Bahar-Fuchs, Woods and Clare2019; Woods et al., Reference Woods, O’Philbin, Farrell, Spector and Orrell2018), I am increasingly aware how difficult it can be to pin down and categorize multicomponent therapeutic approaches. For example, CORDIAL has not been included in reviews of reminiscence therapy, but should it be included in reviews of CBT for depression or of cognitive rehabilitation? Or will we reach a point where such labels will cease to be meaningful as individualization of therapy develops?
Tonga et al. (Reference Tonga, Benth, Arnevik, Werheid, Korsnes and Ulstein2020) make the case that broad, multicomponent approaches are useful because of the heterogeneity of dementia. Equally, it could be argued that the resulting approach risks not having sufficient amounts of any of its components to make a therapeutic difference, and that what is needed is an overall framework within which the right approach can be provided for the individual. As Vernooij-Dassen et al. (Reference Vernooij-Dassen2019) comment, we need to make “progress in relation to what works for whom, when and where” and put paid to the fallacy that “one size fits all”.
Individualized approaches
All three components of the CORDIAL approach lend themselves to a highly individualized approach, with CBT and cognitive rehabilitation benefitting greatly from the scope for setting personal goals and building on individual strengths and resources. Although reminiscence groups are popular, if reminiscence has an effect on depressed mood, it is more likely to be found in individual reminiscence (although not typically in two sessions!) (Woods et al., Reference Woods, O’Philbin, Farrell, Spector and Orrell2018). It is interesting to note that Brueggen et al. (Reference Brueggen2017) reported a small study using CORDIAL in a group setting; reflecting the earlier discussion of CORDIAL not being designed as an intervention for depression, they did not include a measure of depression in their outcomes. Despite a tendency in dementia care to gravitate toward group-based approaches, retaining the individual approach does appear to capture the essence of CORDIAL, although it should be noted that family caregivers also played a key role in the Tonga et al. study, participating in 6 of 11 eleven sessions. These caregivers had remarkably low levels of stress compared with family caregivers in other studies (e.g. Woods et al., Reference Woods2016: Relatives Stress Scale mean 21.8 ± 10.8; Tonga et al., Reference Tonga, Benth, Arnevik, Werheid, Korsnes and Ulstein2020: Relatives Stress Scale mean 12.7 ± 10.4). They may not then be typical of those coming forward for help in a clinical context, and more work may be needed regarding how best to engage dyads of people with dementia and family caregivers to maximize benefits for both parties.
Dementia and mild cognitive impairment (MCI)
In contrast to the other evaluations of the CORDIAL program cited, Tonga et al. (Reference Tonga, Benth, Arnevik, Werheid, Korsnes and Ulstein2020) have not focused exclusively on people with dementia in their sample recruitment. People with amnestic MCI were also included, making up 40% of the overall sample. This may help explain the relatively young age of the sample in comparison with other studies, as well as the aforementioned relatively low stress levels of their family caregivers, many of whom might not have begun to consider themselves as caregivers as such. Of course, depressive symptoms are indeed common in people who are categorized as having MCI (Yates et al., Reference Yates, Clare and Woods2013), but the direction of causality is even less clear in MCI, with the real possibility that at least part of any observed cognitive impairment arises from depressed mood, rather than depressive symptoms being a consequence of cognitive impairment. Again, for the purposes of meta-analyses, pooling data for people with dementia and MCI is problematic; we need effective treatment approaches for people with dementia and people with MCI, but we need to be able to distinguish between them. Reporting results separately for different diagnostic groups would reduce this difficulty, of course.
The CORDIAL approach emerges as a promising psychosocial intervention approach, serving to reinforce the potential, and largely untapped, utility of CBT in this context, here in combination with aspects of cognitive rehabilitation. Focusing further on its potential to reduce depressive symptoms in those people with dementia (and MCI) who have low mood and other indicators of depression would be a valuable way forward. More individualized outcome assessment might assist in the identification of other outcomes, including for those without depressed mood, but who wish to improve and manage their day-to-day function.