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Cognitive Rehabilitation and Memory Enhancement: Evidence-Based Interventions for Older Adults Dr. Rob Winningham Western Oregon University, Northwest Rehabilitation Associates To comply with professional boards/associations standards: I declare that I do have a financial relationship occurring in the last 12 months with a commercial interest whose products or services are discussed in my presentation Scientific Advisor for Linked Senior and Speaker/Teacher for Activity Connection All Planner s involved do not have any financial relationship. I declare that I do not have a relevant non-financial relationship to disclose Requirements for successful completion is attendance for the full day seminar, if not, amended CE will be granted accordingly based on your boards/associations requirements (rules) along with a completed evaluation form. Cross Country Education and all current accreditation statuses does not imply endorsement of any commercial products displayed in conjunction with this activity. Cross Country Education Leading the Way in Continuing Education and Professional Development. www.crosscountryeducation.com Table of Contents Use it or lose it: Maximizing memory ability Memory and cognition Memory and the brain Understanding dementia and memory loss Developing your own cognitive enhancement programs Cognitive enhancement activities: Learning the different types Motivating patients and residents to engage in behaviors that will improve their health and quality of life. 1

Some Facts about Aging and Memory Over 5.3 million older adults in the U.S. suffer from AD 12 million older adults suffer from Mild Cognitive Impairment (MCI) or other more severe disorders affecting memory. 16% of people with MCI develop Alzheimer s Disease each year. 80% of people with MCI will develop AD within six years (Petersen et al., 2005). There Is Hope Take a multifactorial approach to preventing dementia and maximizing memory ability Cognitive exercise Physical exercise Nutrition Social support and loneliness Mood Sleep There Is Hope Reduce risk factors Obesity Diabetes Stress Isolation Smoking Delirium 2

More Hope Older adults grow new neurons Older adults can make new connections and rewire their brains. The organization and connection among neurons is more important than the number of neurons. What causes us to make and maintain connections among neurons? 86 Billion Neurons with up to 20,000 Connections Each (in the cortex) Public domain image from: commons.wikimedia.org/wiki/file:neuron.jpg Cognitive Exercise is the Key Older adults can improve their memory ability with regular cognitive exercise. The Use It or Lose It theory is now widely accepted by scientists. The Reserve Hypothesis is consistent with the Use It or Lose It theory, in that increased neuronal connectivity will lead to better functioning. 3

More Scientific Findings Stimulating jobs are associated with decreased likelihood of having memory problems Having complex and dense ideas early in life is associated with fewer memories problems later (nun study) Increased education is associated with a decreased likelihood of developing Alzheimer s Disease. Recent Scientific Findings July, 2003 - More education provides older adults with a reserve that allows them to function normally in the presence of a brain disease like Alzheimer s.however, because education is a lifelong process, it is possible that elderly people can delay or even prevent the onset of dementia by keeping their brains active. Dr. Mortimer, Director of USF Institute of Aging Recent Scientific Findings March, 2005 - Higher levels of education are associated with different cognitive courses in AD patients. More education is associated with a relative preservation of attention and verbal processes. Le Carret et al., Universite Victor Segalen 4

Recent Scientific Findings January, 2006 -- Reduced volume, or atrophy, in parts of the brain known as the amygdala and hippocampus may predict which cognitively healthy elderly people will develop dementia over a six-year period, according to a study in the January issue of Archives of General Psychiatry by Tom den Heijer et al. New England Journal of Medicine (2003) Dr. Verghese and his colleagues at the Albert Einstein School of Medicine followed older adults for 21 years! The researchers measured the number of cognitively stimulating activities the participants did and whether or not they developed dementia. New England Journal of Medicine (2003) The participants who did the most activities were 63% less likely to develop dementia, as compared to those who did the least. For every additional activity someone did on a weekly basis, there was a 7% reduction in the likelihood of developing dementia. 5

Journal of Mental Health and Aging (2003) The results of the New England of Journal of Medicine article are consistent with the study we conducted at Western Oregon University. We assessed the effectiveness of a comprehensive group based memory enhancement program relative to a control group. This study didn t rely on previous cognitive ability because it was essentially an intervention. Participants: Attended 3 sessions per week in their community. Learned about the brain and memory. Engaged in challenging and fun activities. Exercised many different parts of their brain. Develop better social support networks. Clinical Research Participants in 7 different facilities were tested on many different memory and mental tests. Then 1/2 of the participants engaged in the cognitive enhancement program and the other 1/2 (the control group) did not. Three months later all participants were retested on the same tests. Changes over the three months were analyzed. 6

Memory Ability Increased after Three Months of Cognitive Enhancement Training RiverMead Behavioral Memory Test (Extended) 70 Score on RBMT-E 65 60 55 50 45 Cognitive Enhancement Control Group 40 Time 1 Time 2 Time of Testing Journal of Mental Health and Aging Conclusions If older adults can maintain their cognitive ability, they will require less care and possibly delay or even eliminate the need to go to a nursing home. Cognitively stimulating activities may also postpone symptoms of dementia, which could also delay the need for more intensive care. Dr. Winningham, Journal of Mental Health and Aging Cognitive Stimulation 7

Memory Basics In order to discuss issues related to memory and aging, we need to make sure we understand some basic memory principles. Three stages of making memories Three types of memories Three memory processes A Classic Memory Study Atkinson and Shiffrin (1968) asked participants to listen to a list of 20 words and then immediately write them down, in any order. What would a graph look like if we graphed the percentage of words recalled as a function of their position in the original reading? Would people recall the first words best? The middle words? Or, the last words? This Can Inform Us About Why We Sometime Forget The first words were rehearsed more and made it into long-term memory The last words were recalled at a higher rate because they were still in short-term memory (immediate or working memory) 8

Question What do you think would happen to the curve if we had people do another activity for one minute? Hint: either the primacy or the recency effect will go away. Yes, the recency effect disappears with a short delay. The Effects of the Order in Which Words Were Read on Recall 0.8 Probability of Recall 0.7 0.6 0.5 0.4 0.3 0.2 0.1 Series1 Series2 0 1 3 5 7 9 11 13 15 Order in Which Words Were Read Short-term memory is like a bookshelf: You put new books on one side and that pushes the oldest book off the other side. Your short term memory is like that, you put new ideas in and that pushes the oldest idea out. Unfortunately, our bookshelves are fairly small, probably holding less than seven books (depending on their size). 9

This Can Inform Us About Why We Sometimes Forget The last words were recalled at a higher rate because they were still in short-term memory. The first words were also recalled at a high rate because they were rehearsed more. The words a the beginning of the list actually made it into long term memory. The dip in the middle is due to: Increased distracters Lack of cognitive resources Lack of rehearsal How Can We Improve Memory? So how do we get information from short term memory into long term memory? Rehearsal, rehearsal, rehearsal. Information Overload? Miller (1956) estimated that adults can hold about seven items, plus or minus two, in their short term memory. The capacity of short-term memory is related to intelligence and ability to learn and comprehend instructions. How does the seven items, plus or minus two estimate related to learning, memory, and older adults? 10

Information Overload? Many older adults experience a reduction in their short term memory capacity. In addition, complex information further reduces the capacity. Miller had participants recall simple lists of numbers, whereas you are probably asking participants to hold onto much more complex information (e.g., instructions). A Great Memory Model How do humans learn and make new memories? The Modal Model of Memory helps explain how we make new memories. The Human Capacity to Learn 11

What is affected as adults age? Sensory memory - not affected Short-term or working memory - affected Long-term memory - memories that were stored in the past are not affected unless there has been brain damage or advanced dementia. Making new longterm memories is affected. Any Memory Failure Can Be Attributed to One of the Three Memory Processes Encoding Storage Retrieval What is affected as adults age? Encoding - affected Storage - not affected, in most cases Retrieval - well practiced memories not affected, proper nouns affected, verb generation affected with Alzheimer s disease 12

Three Types of Memory Procedural anoetic, implicit, nondeclarative, automatic Semantic-declarative, explicit Episodic- autobiographical There is a very predictable order of loss. First episodic is lost Then semantic is lost Finally, in some cases, procedural memories are lost That s an example of retrogenesis Dissociation between implicit/ explicit memory People with dementia and/or traumatic brain injury (TBI) can learn implicitly. Or, in other words, they can make new procedural memories. HM: mirror drawing figures 13

Prehabilitation? Wheel chair and walker races for nonusers could develop procedural memories What Abilities Are Preserved (to some degree) in People with Dementia? Procedural learning Recognition What Abilities Are Preserved (to some degree) in People with Dementia? Crystallized intelligence (knowledge, wisdom?) 14

Tap Into Existing Memories and Abilities Life Review Story telling What Abilities Are Preserved (to some degree) in People with Dementia? Classical conditioning Emotional conditioning They may not remember your name They may not remember what you have done But, they will remember how you made them feel What is affected as adults age? Procedural - not affected Semantic - encoding affected some, storage and retrieval not usually affected Episodic - encoding affected, storage and retrieval not affected very much 15

Memory and the Brain Public domain image from: http://upload.wikimedia.org/wikipedia/ commons/4/47/main_brain_lobes.gif Neuroanatomy Occipital lobe - vision Temporal lobe - language Parietal lobe - association cortex Neuroanatomy Frontal Lobe Functions Selective Attention Sustained Attention Inhibition - prevents us from just responding to the environment, rather than executing plans. Regulate social behavior (related to inhibition) 16

A Tale of Two Brains Murderer s Brain Normal Brain Neuroanatomy Frontal Lobe Functions Planning Problem solving Executes motor behavior Neuroanatomy Attentional processes and memory are related. An inability to attend to appropriate aspects of one's environment will impair understanding, memory, and performance. Many problems associated with an impaired ability to be attentive and learn new information can be linked to the frontal lobe. 17

Neuroanatomy We will discuss how to exercise inhibitory processes and thereby improve attentional and memory abilities. Frontal lobes, attention, and memory Not all rehearsal and practice is the same because attentional resources vary. Levels of processing matters (Craik & Lockhart, 1972) and is related to attention. Not All Rehearsal is Created Equal Shallow vs. Deep Processing Maintenance vs. Elaborative Rehearsal 18

Frontal lobes, attention, and memory How can you help patients process information at a deeper level? Predictions Postdictions Retention testing that is announced beforehand Spaced retrieval works! See Sumowski et al., (2010) Mental imagery Put signs in the room (e.g., sternal precaution) Teaching others, group therapy Generation effect Helping Patients Process Information at a Deeper Level: Generation Effect The generation effect refers to an enhanced ability to remember information that is self-generated compared with material that is passively presented. Generating information helps activate the frontal lobes and enhances recall. In addition, generation may lead to greater attention and interest, which can also improve memory performance. (Taconnat & Isingrini, 2004) Recent research found that patients with mild dementia and memory impairment related to MS benefited from self generating information (Basso et al., 2008) By having patients generate solutions to problems they will be more likely to remember the correct behavior. Helping Patients Process Information at a Deeper Level: Generation Effect Errorless learning vs. Generating (incorrect) solutions 19

Demonstration In a moment, you will see a list of words. Please read the color the word is written in, not what the word says. Read the first column, then the second, then the third, and finally the fourth. Example: RED say Red Example: GREEN say Red Please loudly state the color the word which is printed. When you are done with all four columns, please raise your hand. Why Does The Stroop Effect Occur? When viewing the incongruent list (word and color of ink are different) people have a difficult time inhibiting the action of reading words when they are suppose to be stating the color of the ink. Why Does The Stroop Effect Occur? Difficulty with the Stroop Test is a indicative of impaired inhibitory processing (and thus attention and memory ability). The above can be rehabilitated, if caught early enough. The Stroop Materials are available on the website and can be used as an exercise and/or as a way to track changes over time. 20

Sentence Inhibition Activity Instructions: Have participants verbally state a word that is different than the typical response, after you verbally state the first part of the sentence. Understanding Dementia Dementia is a global category of disorders. There are many types of dementia, such as Alzheimer s disease, vascular dementia, dementia with Lewy Bodies, Pick s disease, etc. Dementia and Delirium Dementia is a syndrome of global cognitive decline that most likely occurs for the first time in old age. Dementia is different from delirium which refers to an acute physiological brain dysfunction that developed over a relatively quick period of time. Medication Post-operative effects (51% of hip fracture surgery patients had delirium in a study by Munster et al., 2012) Metabolism issues Food intake Dehydration Infections Sleep Apnea? 21

Mini Mental State Exam Orientation to time Orientation to place Registration Attention and calculation Recall Naming Repetition Comprehension Reading Writing Drawing Scores range from 0-30 When is the optimal time to begin an acetylcholine esterase inhibitor? Molinuevo et al. (2011) found that patients with more mild Alzheimer s (MMSE > 21) responded better than people with more severe Alzheimer s (MMSE < 21) in terms of memory, language, and IADLs (e.g., telephone, preparing meals, managing meds, finances, etc.). 2013, Dr. Rob Winningham All 22

Download the SLUMS and Instructions http://www.elderguru.com/downloadthe-slums-dementia-alzheimers-testexam/ Symptoms of Dementia No two cases are the same but here are some common signs or co-morbid conditions: Depression Left vs. Right Hemispheric Damage Patients who have disease of the left frontal lobe often are sad, anxious and depressed," explains Dr. Kenneth Heilman, a neurologist at the University of Florida College of Medicine. "In contrast... patients with right-hemisphere disease often (appear) indifferent or euphoric and have inappropriate jocularity. Symptoms of Dementia Depression Anxiety Paranoia Inappropriate social behavior Anger Emotional perseveration Delusions Confabulation 23

Probable Diagnosis of Alzheimer s Disease 1. Presence of memory impairment and one of the following: aphasia, apraxia, agnosia (inability to identify objects), or disturbances in executive functioning. 2. The above deficits significantly impair daily functioning and represent a decline from previous performance. 3. There has been a gradual onset with continued decline. 4. The cognitive deficits need to be unrelated to other central nervous system conditions, delirium, medical conditions known to induce cognitive decline, or a substance-induced condition. 5. Cognitive deficits cannot be attributable to other psychiatric conditions such as schizophrenia or major depressive disorder. Most Common Types of Dementia Alzheimer s Early vs. late-onset (and genetics) Vascular (multi-infarct dementia) Parkinson s Associated Lewy Bodies Frontal temporal lobe degeneration (including Pick s Disease) Dementia w/ Lewy Bodies A recent study concluded that DLB is associated with worse visuospatial and executive dysfunction. We also see visual hallucinations, spontaneous Parkinsonism, and alterations in alertness and attention with DLB. The visual hallucinations can be quite severe and medications that are typically used to treat hallucinations and agitation associated with other conditions (i.e., antipsychotic and anti-anxiety medications) often don t work with people who have DLB; they may even exacerbate the symptoms. 24

Picks Disease and Frontotemporal Dementia Frontotemporal dementias, including Pick s disease, are often difficult to differentiate from Alzheimer s disease. personality change language impairment apraxia Impulsivity apathy carbohydrate craving mania grandiose illusions From Rogan & Lippa (2002) Picks Disease and Frontotemporal Dementia It may be worthwhile to try to differentiate Pick s from other types of dementia because the most common class of pharmaceuticals used to treat dementiarelated symptoms (i.e., acetylcholine enhancers) may not help the patient with Pick s disease as much. Moreover, these patients may have adverse reactions to acetylcholine enhancers. Developing Your Own Cognitive Enhancement Program Not reminiscing (unless used to facilitate social interaction) What is cognitively stimulating? Simple rule 25

Cognitive Enhancement Programs What type of activities should a good cognitive enhancement class have? Challenging Fun Stimulating Variety Website Website: gwi.northwestrehab.com Username: instructors Password: trainbrains You will need Adobe Reader, MS Word, and possibly MS PowerPoint Please email me any suggestions, errors found, or materials you want uploaded. Email: rob.winningham@gmail.com Cognitive Enhancement Activities Facts of the Day Memory and Attention Activities Homework Activities Touch Activities Tongue Twisters Poetry Activities Instructions for Many Activities 10 "Easy" Soduku Puzzles 26

Facts of the Day Develop a list of interesting but lesser known facts (see website). Present the fact at the beginning of cognitive enhancement classes. Ask participants at the 1, 4, 10, 20 and 50 minute marks what the fact of the day is. If no one remembers the fact of the day then give them a cue. If after a cue, no one remembers try to phrase a question in a multiple choice format as even early stage dementia patients have relative preservation of their recognition abilities. Facts of the Day Fact of the day: The brain has 100 billion neurons. Ask: What is the fact of the day? If no one correctly responds: Ask: What is the fact of the day? It has something to do with the brain If no one correctly responds: Ask: How many neurons do we have in our brains? If no one correctly responds: Do our brains have 100, 100,000, 100 million or 100 billion neurons. (More impaired patients may benefit from have the alternatives written out.) Facts of the Day Quiz people the next session about previous facts Writing it down is ok but try to get them to make a memory 27

Memory and Attention Alphabetization Activities Anagram Activities Brain Hieroglyphics Buzz Creative Brainstorming Homophones Mind Bending Quiz Newspaper Activities Ping, Pang, Pong Theory of Mind Activities Split Words Word Generation Activities Root-o-nyms State Fun Stroop Activity Trigger Word Activity Buzz Have participants count, beginning in a clockwise direction such that the first person says one, the second person say two and so on. Instruct people to say buzz instead of the number if the number is a multiple of seven (e.g., 7, 14, 21, 28, 35, 42, 49, 56, 63 and so one) or if the number has a seven in the number (e.g., 17, 27, 37, etc.). The direction reverses when someone says buzz in place of the number. Even participants with moderate memory problems can learn this activity, if they do it during every session. This activity requires attention and used the frontal lobes and the right parietal lobe. To make the activity more challenging, split a large group into smaller groups; the noise of the adjacent groups require even greater use of attentional resources. Mental Rotation 28

An Idea for More Impaired or School Children Say A, B, Cs (or count) in a group and point to the next person in the sequence. Everyone has to engage in sustained attention. Creative Brain Storming: Think of as many uses for a BLANK. Participants will generate as many possible uses for a common everyday object. The goal is to try to think as creatively as possible. This activity is challenging for people with Mild Cognitive Impairment and almost impossible for people with dementia (therefore it is probably an excellent activity to prevent future memory problems). Give participants examples of creative ideas to show them that they don t need to generate common uses. For example, if the topic is Use for old newspapers, then give creative examples such as: use it for insulation, use it to soak up an oil leak under a car, line a cat litter box, use it to cut letters out and make a ransom note, etc. After participants have worked on the activity for 3-5 minutes, ask them to try and determine which of their responses were the most unique (i.e., no one else generated the answer(s)). old rowboat dime old car tires old refrigerators cereal boxes paperclip plastic milk cartons Alphabetization Activities Give each participant an envelope full of words. The participant will dump out the words and attempt to put them in alphabetical order. Variations: For beginners, the first letters of each word should be different and the first letter of each word separated by at least 2 letters in the alphabet (i.e., don t have words that begin with R and S). For advanced participants, give them words that begin with the same letter or even the first two letters, also try giving them more words. 29

Newspaper Activities The Newspaper Activity actually involves several different tasks. First, get as many newspapers as you have participants. The newspapers don t necessarily have to be the same; try to get large newspapers (e.g., New York Times or Sunday papers) for high functioning participants and smaller newspapers (e.g., local ones or mid-week papers) for lower functioning participants. Scramble the order of each newspaper, such that all the original pages are there but in random order. Then, give each participant a scrambled paper and ask them to put the pages in the original order, just as they would be in they just purchased the paper. Newspaper Activities After the participants have completed the above task, ask them to find and circles all the m s on the first page. This task can be made more difficult for nondemented participants by asking them to keep a running total of the number of letters they have circled. They should count aloud so participants have to inhibit listening to others. The task can be made even more difficult by having them find and circle 2 or even 3 letters at a time, which is very appropriate for noncognitively impaired participants. Then, after the above task is complete. You can give participants scissors, tape, and blank paper. Ask them to cut out words or letters to make a sentence or poem. The participants can tape the words or letters from the newspaper onto the blank paper. Skit Theory of Mind Cartoon Caption Activities 30

Ping Pang Pong Always go clockwise. The first person says Ping, the second person says Pang, and the third person simultaneously says Pong and points to someone. The person who has been pointed to starts over and says Ping Word Generation Activities A-Z Activity Antonym Activities Name Generation Activities Think of as Many Blank as You Can Think of Things in the Color Verb Generation Activities A-Z First names Last names Female first names Male first names Animals Countries Verbs Things to are alive Things that are not alive (inanimate objects) 31

Think of as many as you can. Examples: animals presidents flowers car types book titles actors male names female names types of dogs and cats desserts countries Generating verbs is a challenging linguistic activity that exercises attention, executive functioning, and word fluency. Recent research suggests that an inability to generate verbs may be a sign of Alzheimer's Disease. Therefore, generating verbs may act in a preventative fashion. This activity is not appropriate for people with some types of dementia. If participants are having a difficult time with this task, remind them that any behavior is ok (e.g., talk, walk, sees) 32

Split Words Begin by printing out sheets linked below, each sheet has approximately 12 words in large font. Cut each word out then cut the word in half. For example, take the word FAMILY and cut it into FAM and ILY. Place all word halves into an envelope. Make enough envelopes for each participant and be sure to label the envelope (e.g., Split Word #1), so you can keep track of which ones you have used and possibly reuse them at other facilities or in 6-12 months. The lists provided are appropriate for people with mild cognitive impairment, they are relative long words and the first letter is capitalized. You can make the task more difficult by using shorter words and/or not capitalizing the first word. Homework Cognitive stimulation is probably dose dependent Homework Important component How much? At least one assignment per class 38 homework assignments on the website Anagrams An anagram is word or phrase formed by rearranging the letters of another word or phrase. For example, Elvis to Lives. This is a fun addition to any cognitive enhancement program. We also have a related activity called word mines. 33

I cnduo't bvleiee taht I culod aulaclty uesdtannrd waht I was rdnaieg. Unisg the icndeblire pweor of the hmuan mnid, aocdcrnig to rseecrah at Cmabrigde Uinervtisy, it dseno't mttaer in waht oderr the lterets in a wrod are, the olny irpoamtnt tihng is taht the frsit and lsat ltteer be in the rhgit pclae. The rset can be a taotl mses and you can sitll raed it whoutit a pboerlm. Tihs is bucseae the huamn mnid deos not raed ervey ltteer by istlef, but the wrod as a wlohe. Aaznmig, huh? Yaeh and I awlyas tghhuot slelinpg was ipmorantt! See if yuor fdreins can raed tihs too. Mental Rotation Tangrams Spatial Activities 34

Simple Math Problems In this activity participants simply complete 24 simple math problems as fast as they can. You can time participants each time and see if they are improving (i.e., taking less time to complete the math problems). This activity is appropriate for most people regardless of the presence of dementia, as doing simple arithmetic is a procedural memory for most people and not affected by dementia too much (unless there was a stroke that affected a discrete brain area). Other Activities Dual tasking Mobility and cognition Touch Smell Pictures of participants (new and/or old, close up of face parts) Tray of items (Kim s Game) Count in Roman Numerals ( I, ii, iii, iv, v ). Others? Evaluations Seminar # 096799 Registration # on the front of your book 35

Developing Your Own Geriatric Wellness Program Screening? Levels? Screening participants Meet with potential participants Use the MMSE or better yet SLUMS Cut off scores (MMSE) Advanced 25-26+ Beginning 16-24 Cut off scores (SLUMS) Advanced 21-22+ Beginning 12-20 Personality and social skills Sometimes you will have to turn away a potential participant who could benefit from the class Class Levels Try to have two class levels If that is not possible you can challenge more capable participants by: Ask recall questions More challenging homework Extra homework (list of homonyms; think of as many words with the letters M-E-M-O-R-Y) Have them help run the classes Have them help lower functioning participants outside of class (e.g., homework or extra activities) 36

Class Levels Have higher functioning participants: Keep track of attendance Keep track of homework Enlist new participants Develop a newsletter for the class with an article, activities, and pictures Develop a photograph project New Old Class Levels Have higher functioning participants: Create a word find (or word search) using other participants names Create a crossword puzzle using facts of the day or facts about participants Create a jeopardy game using previous facts of the day Memorize a poem (or a new tongue twister) and recite it for the group. Develop a book club (librarian?) Teach a computer class How to Conduct Group-Based Classes A common session Facts of the Day Buzz Activities Homework (at the end of the session) Distractions Try to reduce distractions when initially teaching people how to conduct an activity. After people know how to conduct an activity, you can try to increase distractions to increase frontal lobe exercise. Break up into smaller groups to increase vocal distractions Add extraneous noise 37

How can we overcome the effects of depression, apathy, and amotivation in order to maximize program efficacy? Increase motivation for the rehabilitation process. Increase self efficacy Increase perceived outcome expectations (What is in it for me?) Self Efficacy Self efficacy is the belief that one has the capability to manage the demands of a challenging situation in such a way as to attain a desired outcome (Bandura, 1977). Patients who have a higher self efficacy will be more likely to fully participate in the rehabilitation process. Self Efficacy You can help patients increase their self efficacy by providing opportunities for them to succeed Show them objective measures of their success they have had. 38

Self Efficacy Use video to document improvement (e.g., walking) Start and end with a successful experience Use appropriate cues to facilitate success Free recall Cued recall Recognition Recommendations for Patients with Low Self Efficacy Experiences in mastering new skills and overcoming obstacles will increase self efficacy. Vicarious experiences provided by successful models who are similar to oneself. Stories of similar participants who have succeeded. Put success stories in the newsletters. Encouragement and persuasion can also increase self efficacy. The Other Half of the Motivation Equation Perceived Outcomes or What is in it for me? 39

Make sure people know the benefits of a certain behavior or therapy Make the therapy relevant to the depressed patient. Work Parenting School Pets Spouse Hobbies Live independently Maintain some independence Maintain mobility Reduce pain Ask the patient what their goals are ( What do you want? ) What happens if they don t do therapy or seriously engage activity programming? Protection Motivation Theory It is another strategy How Can Bill for Cognitive Rehab? Working on sustained attention for moderately difficult problem solving How many cues do they need? 40

How Can Bill for Cognitive Rehab? Write goals that involve education or a home exercise program as well or education/assessment of use of strategy in functional environment Pt. will demonstrate use of compensatory sequencing/problem solving strategy 3 times (such as use of check list) during functional iadl activity Pt. will independently use executive functioning skills to complete functional activities such as planning and organizing current medications How Can Bill for Cognitive Rehab? Write goals that involve education or a home exercise program as well or education/assessment of use of strategy in functional environment Pt. will demonstrate ability to perform cognitive home exercise program targeting executive functioning with independent initiation of exercises and independent use of log to track completion Pt. will perform functional and structured problem solving tasks with 80% accuracy How Can Bill for Cognitive Rehab? Consider long term goal and rationale for skilled services by documenting: Recommend continued skilled speech therapy services for ongoing assessment and treatment for safe communication and cognition skills to complete ADL activities. The skill is selection of treatment materials to fit the linguistic and cognitive ability of the particular patient that is appropriate for challenging cognitive communicative function without causing frustration and that will be motivating/relevant to the patient. 41

Other Factors That Affect Memory Ability We must take a holistic and multifactorial approach to preventing memory problems and maximizing cognitive functioning: Physical exercise Nutrition Social support Mood and depression Stress and anxiety Exercise and Cognition Colcombe and Kramer (2003) reported the results of an 18-study metaanalyses on the effects of exercise on cognition. They found that, on average, exercise programs lead to a.5 standard deviation increase in cognitive abilities (e.g., I.Q. of 100 versus 108). Exercise and Cognition Kramer et al. (2001) found that participating in a six month walking program led to increased attention in 60-75 year old adults. Scarmeas et al., (2009) found that older adults (mean age 77 years) who were in the top third in terms of getting physical exercise were 61% less likely to get dementia 42

Exercise and Cognition Liu-Ambrose et al. (2010) reported that 12 months of weekly resistance training resulted in an 11% increase in executive functioning, in an older adult population. What type of exercise is best? Nagamatsu et al. (2012) found that twice a week resistance training in 70 to 80 year old women, with Mild Cognitive Impairment, led to significant improvement in attention and memory ability. Nutrition and Cognition Fats Antioxidants 43

Good Fat Omega-3 fatty acids or good fat has been linked to improved cognitive functioning in older adults. Fish, nuts, olive oil, canola oil, and green leafy vegetables are high in Omega-3 fatty lipids. Research Research has found a positive correlation between Omega-3 fatty acids levels (e.g., DHA) and cognitive functioning in older adults. Individuals with dementia often have lower levels of DHA than non-demented controls. The more fish people eat, the less likely they are to show signs of Alzheimer s Disease. The American Journal of Clinical Nutrition (2009) Albanese et al., (2009) studied 15,000 people in Latin America and Asia found that those who ate fish nearly every day were 20% less likely to get dementia as compared to those who ate it only a few times a week. Those that ate fish a few times per week were 20% less likely to get dementia than those who rarely ate fish. 44

Research Recent research has also shown that fish oil tablets can decrease the number of depressive symptoms in people diagnosed with major depression. Some studies have found that fish oil tablets are as effective as modern antidepressants. Research The omega-3 fatty acids might reduce inflammation in the brain. Inflammation might be one of the causes of Alzheimer s disease. It also may be that myelination of the axon is affected by our dietary intake of fat. Why should you eat your fruit and vegetables? 45

Antioxidants Over time, our brain cells experience wear and tear from various oxidants known as free radicals (as well as cell division). Our bodies use antioxidants to combat the effects of free radicals. Antioxidants The Top Antioxidant Fruits and Vegetables* Food Antioxidant Power** Prunes 5770 Raisins 2830 Blueberries 2400 Blackberries 2040 Cranberries 1750 Strawberries 1540 Spinach 1260 Raspberries 1230 Brussels Sprouts 980 Plums 950 46

The Top Antioxidant Fruits and Vegetables* Food Antioxidant Power** Broccoli Florets 890 Beets 840 Avocados 780 Oranges 750 Red Grapes 740 Red Bell Peppers 710 Cherries 670 Kiwis 600 * - Based on Small (2002), p. 141-142 ** - Oxygen Radical Absorbency Capacity (ORAC) per 3.5 ounces The Importance of Social Support Virtually all older adults have experienced disruption of their social support networks. These disruptions are often ignored and can lead to a myriad of mental health problems. Emotional and Social Losses Death of a spouse Death of close life-long friends Health problems may affect socialization Inability to drive Move away from friends Less likely to have social contact through work 47

Why is social support important? Depression/Despair/Hopelessness Cardiovascular Health Immune Functioning Cognitive Maintenance Cancer Prognosis Life Expectancy Cognitive Enhancement Training Led to Increased Social Support The Effects of a Cognitive Enhancement Program on Social Support Appraisals 77 76 75 Score on SS-A 74 73 72 71 70 69 68 Cognitive Enhancement Control Group Time 1 Time 2 Time of Testing Cognitive Enhancement Training Led to Decreased Loneliness The Effects of a Cognitive Enhancement Program on Loneliness 35 UCLA Loneliness Scale 34 33 32 31 30 29 Cognitive Enhancement Control Group 28 Time 1 Time 2 Time of Testing 48

How to Enhance Social Interaction/Support Photograph projects New Old Parts Shadows Back of head Resident directories How to Enhance Social Interaction/Support Resident Ambassadors New neighbor notes on doors Know your neighbor sessions Treasure (facts about residents) hunt for staff How to Enhance Social Interaction/Support Affinity Sessions Travel Teachers Mechanics 49

Social Engagement Activities Guess who? Provide cues regarding a resident Put one or two cues a day up on a board Person, place, thing Provide cues on a board over a number of days You can use the same board Social Engagement is Stimulating July, 2008 - Berkman and her colleagues found that older adults who were most socially engaged had the least memory problems. Social Engagement is Stimulating The working hypothesis is that social engagement is what makes you mentally engaged,' said Lisa F. Berkman, the study s senior author and director of the Harvard Center for Population and Development Studies. You can t sit and withdraw if you re constantly talking and working on things and figuring out problems in your daily life. It s not just completing a crossword puzzle, it s living your life.' From: http://well.blogs.nytimes.com/2008/06/04/socializing-appears-to-delay-memory-problems/ 50

Summary Multifactorial Approach to Maintaining Quality of Life in Older Adulthood. Cognitive Stimulation Physical Exercise Nutrition Social Support Depression Stress and Anxiety Pharmacological Interventions Maximize Motivation Website Website: gwi.northwestrehab.com Username: instructors Password: trainbrains You will need Adobe Reader, MS Word, and possibly MS PowerPoint Please email me any suggestions, errors found, or materials you want uploaded. Email: rob.winningham@gmail.com Contact Information Dr. Rob Winningham Professor & Chair of Psychology Western Oregon University 345 N. Monmouth Ave Monmouth, OR 97361 Email: winninr@wou.edu Phone: (503) 838-8344 51

Common Questions You Could Answer Based on the Information Presented 1. Given all of the evidence for the Use It or Lose It Theory, why did Ronald Reagan get Alzheimer s disease? 2. Why can my grandma recall poetry that she learned when she was 8 years old, but not her phone number where she lives now? 3. I am being told that dad has dementia and needs to move somewhere that has 24 hour support. I don t believe it. He can still tell you how to rebuild a carburetor and tell you who won the World Series back in the day. How would you explain dementia and the adult child s observations? 4. All this talk of dementia is depressing. Is there any good news about memory for older adults? Do older adults maintain or even improve any aspects of cognition? 52

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Cognitive Rehabilitation and Memory Enhancement Robert Winningham, PhD 1. It is possible for older adults with mild cognitive impairment to improve their memory ability with regular cognitive exercise. a. true b. false 2. There are only a few types of dementia. a. true b. false 3. Older adults can grow new neurons. a. true b. false 4. According to the lecture video, people who have higher education levels have a relative preservation of spatial abilities if they develop Alzheimer s disease. a. true b. false 5. New neurons can be created almost everywhere in older adults brains. a. true b. false 6. New neurons can be created in older adults hippocampus? a. true b. false 7. Obesity is a risk factor for developing dementia. a. true b. false 8. Which of the following is not one of the three memory stages seen in the Modal Model of Memory? a. procedural memory b. sensory memory c. short term memory d. long term memory

9. The primacy effect is caused by: a. the information that is currently in sensory memory b. the information that is currently in short-term memory or working memory c. the information that is currently in long-term memory d. the information that is forgotten 10. The recency effect is caused by: a. the information that is currently in sensory memory b. the information that is currently in short-term memory or working memory c. the information that is currently in long-term memory d. the information that is forgotten 11. What did Miller (1956) estimate the capacity of short-term memory to be (for digits)? a. 3 plus or minus 2 b. 5 plus or minus 2 c. 7 plus or minus 2 d. 9 plus or minus 2 12. Which of the following is not a type of memory that was presented as being one of The Three Types of Memory? a. procedural b. semantic c. episodic d. reoccurring 13. People with dementia can usually make which type of memories? a. declarative b. semantic c. episodic d. procedural 14. Memory failures are caused by: a. a failure to encode b. a failure to adequately store information that has been encoded c. a failure to successfully retrieve d. all of the above are possible causes of memory failures 15. Which type of memory is LEAST likely to be negatively affected by brain injury? a. episodic b. semantic c. procedural d. flashbulb

16. A difficulty generating is indicative of Alzheimer s disease. a. nouns b. proper nouns c. verbs d. adjectives 17. The occipital lobe is responsible for: a. attention and inhibition b. vision c. hearing and language d. sensing touch 18. The temporal lobe is responsible for: a. attention and inhibition b. vision c. hearing and language d. sensing touch 19. The frontal lobe is responsible for: a. attention and inhibition b. vision c. hearing and language d. sensing touch 20. The Stroop Effect is caused by: a. the fact that reading is a procedural memory that must be inhibited b. long-term storage failures c. psychologists are not sure what causes it d. sensory memory failures 21. It is not possible to enhance executive functioning. a. true b. false 22. Errorless learning is only for people who can easily make a new declarative memory, i.e., semantic or episodic. a. true b. false 23. Generating information helps activate the frontal lobes and enhances recall. a. true b. false

24. If you process or rehearse information at a deeper level then you are LESS likely to remember that information. a. true b. false 25. Dementia and delirium are the same disorder in terms of causes and future prognoses. a. true b. false 26. Based on information presented, which of the following is not a common cause of delirium? a. urinary tract infections b. dehydration c. excessive physical exercise d. polypharmacy 27. Based on information presented, what is the commonality among these comorbid dementia symptoms: depression, anxiety, paranoia, inappropriate social behavior, and anger? a. multiple sclerosis b. impaired inhibition c. high consumption of antioxidants d. impaired verbal processes 28. The presence of depression doesn t matter in the diagnosis of dementia (i.e., it isn t factored into the diagnostic criteria at all). a. true b. false 29. Dementia with Lewy Bodies is probably the most common type of dementia? a. true b. false 30. Vascular dementia is probably the most common type of dementia. a. true b. false 31. Alzheimer s disease is probably the most common type of dementia. a. true b. false

32. Based on information presented, which type of dementia do we see variations in executive functioning (i.e., they have good days and bad days ). a. Alzheimer s Disease b. Dementia with Lewy Bodies c. Parkinson s Related Dementia d. Pick s Disease 33. Based on information presented, cognitively stimulating activities that exercise attention and inhibition are going to be the most likely to generalize to other areas of life. a. true b. false 34. Mental rotation activities are going to activate and exercise the same areas of the brain that word generation activities do. a. true b. false 35. Skit and cartoon caption activities can exercise Theory of Mind. a. true b. false 36. There are really no ways to make anagram activities easier for people who are less cognitively capable. a. true b. false 37. Based on information presented, which two factors are associated with motivation? a. self-esteem, age b. self efficacy, age c. self-esteem, perceived outcome expectations d. self efficacy, perceived outcome expectations 38. Based on information presented in the video lectures, it appears that physical exercise improves: a. almost all cognitive abilities b. just social abilities c. attention d. none of the above 39. Resistance or strength training can improve executive functioning. a. true b. false

40. Based on research presented in the video lecture, in order to get any cognitive benefits from resistance training, one would need to do it almost every day of the week. a. true b. false 41. There is evidence that antioxidant supplements could shorten life expectancy. a. true b. false 42. The more fish people eat, the less likely they are to show signs of Alzheimer s disease. a. true b. false 43. Antioxidants can neutralize free radicals. a. true b. false 44. Based on information presented, it doesn t matter whether someone has a good social support network rather it is their belief that they have a good social support network that is associated with positive health outcomes. a. true b. false 45. Which of the following could be considered an emotional or social loss for an older adult? a. Death of a spouse b. Death of close life-long friends c. Health problems that affect socialization d. All of the above 46. Based on information presented, the loneliest older adults are more likely to develop dementia. a. true b. false 47. Unfortunately, based on information presented, it probably isn t possible to improve perceptions of social support and loneliness in older adults. a. true b. false