Introduction and Overview
Today’s seminar is the second installment of a two-part series. In the first session, we provided some foundational knowledge as it relates to the assessment of persons with dementia. We will continue today with the focus on abilities-based approaches to treatment of persons with dementia. Any time we see a diagnosis of dementia, or a diagnosis tied to cognition, we typically know that it's related to a progressive, neurological disease process. Unfortunately, due to the nature of those disease processes, there can be a focus on impairment. We want to change that mindset, and through the assessment and treatment process, always focus on residual abilities present, when developing our individualized plans of care.
As we begin, we will review impairments versus abilities for individuals in the mild, moderate and severe phases of dementia. When we begin discussing evidence-based practice as it relates to intervention, there are two ways that we intervene. We are either, compensating for functional impairments, or we are restoring function. We will discuss the evidence base for each, including a review of techniques for error free learning to promote success. Any time that we are working with persons with dementia, particularly when we are getting into the moderate or later stages of the disease process, it's essential for us, as clinicians, to deliver care in an error free environment, in order to promote success. We will review specific ADLs, including gait, as it relates to cognition. We will also discuss interventions for very low level patients. And, secondly, we will take about how we can restore cognitive function. There is this concept of dual tasking, that we will discuss, that essentially taxes the cognitive system, and there's a relatively strong evidence base there for restoring cognitive function. Then we will also talk about Spaced Retrieval Therapy. When you look at the evidence base for restoring cognitive function, particularly methods for improving functions that are related to reduced short term memory, Spaced retrieval is one of the very few interventions that we have, so we will discuss how Occupational Therapists can tie Spaced Retrieval Therapy into their unique skilled interventions to promote success for persons with dementia.
A key factor that we need to consider with intervention is the fact that we need an interdisciplinary, multi-disciplinary, inter-professional approach to treat these individuals. Why is that necessary? We know that there are over 70 different types of dementia, and when we are looking at the geriatric population, there is a significant increase in incidence between the ages of 65 and 90. It's essential that we have all therapy disciplines (PT, OT and SP) intervening as appropriate, because there is a lot to be said about cognition that occurs when people move. There's a significant evidence base that ties gait control and movement into cognition. We know that gait control is a complex brain process, and recent reviews confirm the importance of the central nervous system, even in non-demented individuals. Additionally, poorer short term memory, and executive function, have been associated with slow gait speed, and simple gait tasks.
Gait is not tied only to physical therapists – as occupational therapists, when we are completing activities of daily living, we need folks to get up and move around their environment. Often, when a person has a cognitive impairment, one the first outwardly visible signs of impairment is manifested in that person’s movement. The initial motor signature that points to a cognitive decline is tied to movement. It's essential that we have all therapy disciplines intervening, as appropriate, so that we're picking up on those changes.
There was a study conducted in 2014 at an institute affiliated with the University of Montreal. The study subjects were between 62 and 84 years of age. Two different groups were assigned high intensity aerobic and strength training, and the third group was performing tasks that targeted gross motor skills, including coordination, balance, ball toss, locomotion and flexibility.
The release notes found that while the aerobic and strength training were the only exercises that led to increased physical fitness, all three groups improved cognitive status. They were tasked with doing these physical-based interventions, tied to motor planning, balance and aerobic intervention, but all groups saw improvements in cognitive status. These results suggest a direct link between physical movement and performance of activities of daily living, and cognitive function. Which therapy discipline is going to pick up on all of those factors and how they interplay? It’s going to be the OTs that are tying in ADL function, movement coordination and balance, in addition to the cognitive element. These all involve different areas of the body, but they are all interrelated.
