Rehabilitation of Elderly Adults with Severe Cognitive Impairment: It is Time for Evidence

The article by Poynter and colleagues1 adds important information to the growing body of literature on the rehabilitation of older adults with dementia. This topic has several important clinical, organizational, and economic implications. In recent years, an increasing number of reports have shown that the rehabilitation of this group of individuals is not only possible and feasible, but is also clinically relevant. People with dementia and hip fracture2 and other nonspecific medical conditions have been successfully rehabilitated in various studies, despite the severity of their cognitive impairment.1, 3 Furthermore, unconventional and technology-based techniques are now promising strategies to overcome the gap of cognitive impairment in these individuals.4, 5 Despite these positive remarks, motor rehabilitation of older adults with dementia is far from being an evidence-based discipline. A crucial question is the lack of randomized clinical trials, which are the only way to draw definite conclusions about the effectiveness of rehabilitation in individuals with dementia. For instance, in the field of hip fracture rehabilitation—a topic expected to become prominent in the coming years given the progressive aging of the population6—there are only two randomized clinical trials including individuals with dementia.7, 8 Of these, only one,8 a small subgroup analysis of a previous multicomponent clinical trial to reduce postoperative delirium in elderly adults with hip fractures,9 used a definition of dementia according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria. The results of randomized controlled studies in individuals with dementia will provide important information to physicians and policy-makers to dedicate adequate resources to the rehabilitation of these individuals, avoiding nihilistic approaches or preconceptions. A definitive multicenter study should be designed, carefully defining the selection criteria of the population to be included, the rehabilitative procedures, and the outcomes of interest. In particular, a rigorous definition of dementia should be used to identify the inclusions criteria, not only according to the Mini-Mental State Examination score; the procedures of the rehabilitative intervention need to be described providing a specific and formal approach; short- and long-term functional and cognitive outcomes should be carefully defined. Because a criterion standard approach is lacking, different lines of intervention need to be evaluated, for example, designing a study with different arms to test the efficacy of each intervention. Specifically, there is a lack of consensus on the limits of rehabilitation related to the severity of cognitive impairment, comorbidity level, the peculiarities of intervention, the intensity and time of rehabilitation, the most appropriate assessment instruments, and postdischarge living situation.10 We are well aware of the difficulties of this approach, but it represents the only way to reach convincing and definite evidence on the efficacy of rehabilitation in older persons with dementia. Conflict of Interest: The authors declare they have no financial or any other kind of personal conflicts with this paper. Author Contributions: All authors: Study concept and design, and preparation of manuscript. Sponsor's Role: None.