OSC 605 Cognition Lecture 2024 PDF

Neurocognition: Assessment and Intervention Megan Mueller, OTD, OTR/L, BCPR 2024   Explain OT’s unique view and role in assessing and addressing functional cognition,  Compare and contrast models to guide cognitive intervention (DIM,...

Neurocognition: Assessment and Intervention Megan Mueller, OTD, OTR/L, BCPR 2024   Explain OT’s unique view and role in assessing and addressing functional cognition,  Compare and contrast models to guide cognitive intervention (DIM, NFA, CDM).  Describe common top down and bottom up cognitive assessments. Class Objectives  Examine common interventions for awareness, attention, memory, and executive functioning.  Analyze strategies to include functional cognition in the acute care setting.  Evaluate interventions to support clients with dementias and their care providers.  Cognition The ability of the brain to process, store, retrieve, and manipulate information (1) It involves the skills of understanding and knowing, the ability to judge and make decisions, and an overall environmental awareness. (1) Functional Impairments include: (not an exhaustive list) (1)  Impaired alertness/arousal  Impaired  Decreased response to environmental stimuli organization/sequencing6  Anosognosia2  The inability to organize Cognition  Unawareness of a deficit  Impaired attention3 thoughts with activity steps properly sequenced  Perseveration7  Inability to attend to or focus on  Continuation or repetition specific stimuli of a motor act (premotor  Disorientation4 perseveration) or task  Lack of knowledge of person, place, (prefrontal perseveration) time, and situation  Impaired problem solving8  Memory loss5  Inability to manipulate a  LTM- lack of storage, consolidation, fund of knowledge and retention, and retrieval of information apply this information to that has passed trough working new or unfamiliar memory situations.  STM: lack of registration and temporary storing of information received by   Functional Cognition:  Can be defined as the ability to use and integrate thinking and performance skills to accomplish complex everyday activities, including IADLs (Giles et al., 2017).  Relates to all resources that are used by the client to Unique meet the requirements of daily living.  Evaluating functional cognition is intended to indicate Perspective the client’s ability to manage everyday ADL and IADL on challenges.  Focuses on bringing cognitive skills to bear on the Cognition performance of activities in a dynamic context.  Reflects the dynamic interplay among client factors, activity demands, environment, and contextual factors.  Is a construct that is applicable across most settings and populations with whom occupational therapy Presentation Title practitioners’ work. Goes Here and Ca n be on Multiple L ines Functional Cognition: Under standing the Importance to Occupational Therapy | AOT A   As OTPs, are we “Working on cognition”  VERSUS  Are we, “Improving participation and quality of life for individuals with cognitive impairments.”  Working on a math equation worksheet to address Unique organization  VERSUS Perspective  Working on paying credit card bill online to ensure success due to executive functioning/organization on impairments Cognition  Working on recall of a string of numbers to address memory  VERSUS  Working on creating a list via a preferred strategy due to memory impairments then generalizing this strategy to various tasks/contexts   Evaluations and Assessments  Focus on client’s performance of relevant occupations  How does a low memory score on the MOCA impact occupations???  MOCA gives you a score, you need to then interpret if that score means anything to that person and their occupational engagement  Goals  Relate to improving occupational performance  Client will increase sustained attention to 10 minutes. VS Unique  Client will engage in shopping task x 10 minutes mod I w/o VCs for re-direction in 2 weeks. Perspective  Interventions  Graded relevant occupations in natural(-ish) contexts with utilization of cognitive on models/strategies  Addressing attention by focusing on shape, size, and color of beads while being Cognition threaded on a string VS  Utilizing task and environmental analysis to gradually increase task demands with appropriate cuing to address attention to preferred (and possibly non preferred tasks).  Outcomes  Improved performance in areas of occupation  Pt increased MMSE score by 6 points VS  Pt is now able to organize 4 novel medications into weekly organizer w/o cues in low stim environment utilizing cognitive strategies   Out of Date Perspective: It was assumed that remediation of an identified impairment or impairments would generalize into the ability to perform meaningful, functional activities.  Example: If I focus on improving organization skills via drills and worksheets, the client will be better able to Unique organize in desired occupations and improve performance/independence. Perspective on  THIS ASSUMPTION HAS NOT BEEN SUPPORTED BY EMPIRICAL RESEARCH. Cognition  Current evidence embraces interventions that focus on strategies for living independently, with a purpose, and with improved quality of life despite the presence of cognitive impairments. Models Guiding Cognitive Intervention   Cognition is a product of the interaction among the person, activity, and environment1  Practice of a targeted strategy with varied tasks in diverse situations (1)  Utilizing varying treatment environments #1:  Emphasizes metacognitive skills as the bases of learning and Dynamic generalization of learning  Metacognition: self awareness of strengths and deficits Interactiona  Awareness questions are used by the OTP to help the client detect errors, estimate task difficulty and predict outcomes l Model  “How do you know this is right?” (DIM)  Emphasis transfer of information from one situation to the next  Transfer of learning must be taught from one task to the next  It does not occur automatically  Occurs through a grade series of tasks that decrease in similarity  Train a client to use scanning strategies for neglect during a matching card game. Use these scanning strategies to locate items on sink top. Use these scanning strategies to locate items in fridge. Use these scanning strategies to locate items in gift shop.  Can be used with adults, children, and adolescents.   Joan Toglia used the DIM to develop the Multicontext Treatment Approach1  Combines remedial and compensatory strategies  Focus on teaching a particular strategy to perform a task and practicing this strategy across different activities, situations, and environments over time (transfer of learning-> generalization). #1:  Components include: Dynamic  Awareness training  Metacognition: self-awareness of strengths and deficits; knowing about knowing 2. Interactiona  Can use questions during task “How do you know this is right” to assist with error prediction and detection l Model  Treatment activity is based on client’s interests and goals (DIM)  Processing strategies should be practiced in a variety of tasks and situations  Transfer of learning is the ability to take a strategy used with one task and apply that strategy to a new task  Transfer of learning must be taught, does NOT occur automatically  Generalization (transfer a skill learned in one context to another context) is the goal  Interventions should occur in multiple environments to promote generalization of learning  Multi-contextual  #1: Dynamic Interactiona l Model (DIM)  #1: Dynamic Interactiona l Model (DIM)   Developed for clients with severe cognitive impairments due to acquired brain injury  Clients with potential for neuroplasticity  Clients with minimal insight into impairments  Anosognosia #2:  Overall compensatory approach with some remediation components Neurofuncti  Focuses on retraining real world skills rather than cognitive perceptual processes (1) onal  Contextual and metacognitive factors are considered during intervention Approach planning  Does not target the underlying cause of the functional limitation but focuses (NFA) directly retraining the skill itself.  Chance for generalization is minimal  Focuses on task specific training  True contexts are important  Intervention utilizes task specific training and repetition with goal for automaticity  Relies on routine, cues/chaining and errorless learning  #2: Neurofuncti onal Approach (NFA)  DIM vs NFA? Functional Cognition: Under standing the Importance to Occupational Therapy | AOT A   Originally developed for use with individuals with psychosocial dysfunction. Now being utilized with persons with neurologic dysfunction and neurocognitive disorders. (1)  Clients typically have little potential for neuroplasticity  Compensatory model  Establish, Maintain, Restore #3: Cognitive  Cognitive functioning is on a continuum (level 1-level 6)1 Disabilities  If a cognitive level cannot change, adapting the activity provides opportunities for the Model individual to succeed (CDM)  Intervention focus is on adaptive approaches and strengthening residual abilities2  Establish Allen’s level then present routine tasks (within that level) that the person can perform OR that have been adapted so that they can perform them. (1)  Goal is to maintain the individual’s highest level of function  Care provider involvement/training Assessments Quality Toolkit | AOTA   Utilization of observation skills to determine which underlying cognitive deficits are interfering with functional performance1  Errors in performance are allowed to occur as long as they are safe and not severe enough to halt performance/harm client. 2  Look for: Non-   Attention Standardized Memory  Insight Structured   Organizational skills Initiation Observation   Termination Executive Functioning (terms under EF vary)  Decision making  Problem solving  Planning  Self-Correction  Sequencing complex actions  Judgement   Majority of cognitive assessments are pen and pen based/tabletop assessments  Why do you think?1  In the OT research and clinical community there is a growing demand to utilize assessments that focus Cognitive more on activity and participation Assessment s  Emphasis on ecological validity  The degree to which the cognitive demands of the test theoretically resemble the cognitive demands in the everyday environment (aka FUNCTIONAL COGNITION)  High ecological validity identifies difficulty performing real-world functional and meaningful tasks.   Modified Barthel Index  Clients with Brain injury, Stroke, Parkinson’s, Older adults/Geriatric care  Top Down (10 ADL/mobility activities Assessment including: 1) Feeding 2) Bathing 3) Grooming 4) Dressing 5) Bowel control 6) Bladder control 7) Toileting s 8) Chair transfer 9) Ambulation 10) Stair climbing)  00-20 total dependence; 100 independent  Less than 40 unlikely to DC home; 85+ DC to community living  Microsoft Word - bb000306.doc  St. Louis University Mental Status Test (SLUMS)  Older adults/geriatric care, Alzheimer’s, progressive dementia  Bottom up  HS education: 27-30 normal, 21-26 mild neurocognitive disorder, 20 or less dementia  Less than HS education: 25-30 normal, 20-24 mild neurocognitive disorder, 19 or less dementia  Microsoft Word - SLUMS Figures.docx   Multiple Errands Test (MET)  Clients with neurological disorders (CVA, PD), Progressive dementias  Top down EF assessment in Assessment real-life environment (home, hospital, virtual versions); s adapted by the clinician to match the motor skills of client and environment (client must complete tasks, obtain information, meet the clinician at a time/place, Assessment inform clinician when task is completed)  Multiple Errands Test | s RehabMeasures Database  Mini Mental State Exam (MMSE)  Older adults, clients with CVA, PD, progressive dementia, ABI  Bottom up  24-30 no cognitive impairment  18-23 mild cognitive impairment  0-17 severe cognitive impairment  Mini Mental Scale.indd   Cognitive Performance Test (CPT)  Dynamic Lowenstein Occupational Therapy Cognitive Assessment (DLOTCA) Assessment  Executive Functioning Performance Test (EFPT) s in Lab  The Kettle Test  Test of Everyday Attention (TEA)  Weekly Calendar Planning Activity (WCPA)  Quality Toolkit | AOTA Documentation   Focus on what you as the clinician did to increase participation of the client  If the client did the task so well, why are we working on it?  How did you structure the environment, the task, the objects used in the task, the time of day, the way you verbalized the task, the cues you used  We need to give ourselves credit for how we are analyzing cognitive tasks to enhance our client’s engagement/performance.  If we are addressing cognition, need to bill for it  As insurance allows Cuing  Focus on progression from most invasive cue to least invasive cues in both goal writing and objective of session Hierarchy Awareness   Management of awareness deficits is a foundational intervention for clients with cognitive dysfunction  May see it documented as: limited awareness, lack of insight, unawareness, anosognosia, lacking metacognition (awareness of cognition)  Denial is different! Considered a psychological process, subconscious.  Needs to be evaluated before creating an intervention program1  If they are demonstrating anosognosia, what cognitive model would not be a good for them?  Need to address awareness first, and then could potentially utilize this model if client develops awarenss Awareness  Three interdependent types of awareness:  Intellectual awareness  Understand at some level that a function is impaired  Emergent awareness  Recognize a problem when it is actually happening  Anticipatory awareness  Anticipate that a problem will occur/more likely to occur as the result of a particular impairment in advance of actions  Persons may be impaired across all three OR have better skills in one or more domains.   Provide feedback  Cues are used to facilitate insight and to encourage the client to solve problems by developing new strategies to overcome deficit areas.  Use video feedback  Client watches the task performance and compares actual performance to what the client stated pre-performance  Prediction methods  The goal is to have the person predict how well they will perform a tsk of interest and then have them compare their prediction to their actual performance through a discussion with the OT  Can predict: how difficult the task will be, how long it will take them, how many Awareness errors they may make, how much assistance they will require  Before, During, After (For example: “How long do you think this will take you?”, Intervention “How much time do you think passed?”, “How long do you think that took you?” Then provide the time.)  Peer Feedback  Role reversal  OTP performs the task just as the client did, and then client tries to detect errors.  Experiential feedback experiences  Planned failures with high levels of OTP support  Client developing awareness is a good thing!!!!  Right???  Monitor for increased signs of depression and anxiety as awareness increases Attention   Attention is considered a prerequisite for all other higher cognitive systems such as memory and executive functions  If a person does not attend to incoming information and cannot hold on to information in their mind, information will not be remembered and cannot be used to guide appropriate behavior or successfully complete daily Attention activities  Most commonly observed deficit after brain injury  Relationship between attention impairments and awareness of errors  Why do you think this relationship exists?   Arousal- state of responsiveness to sensory stimulation 1  Prefrontal area  Selective attention- processing and filtering of relevant information in the presence of irrelevant stimuli2  Prefrontal and anterior cingulate areas  Attend to one conversation at a party  Sustained- maintaining attention over a period of time 3 Attention  Prefrontal area of right hemisphere; Impairment is linked to white matter damage  Watching a movie Terminology  Attentional switching/Alternating attention- switch from one concept to another 4  Prefrontal cortex, posterior parietal lobe, thalamus, midbrain  Cooking, answer the door, return to cooking  Divided- attention between two or more tasks simultaneously 5  Driving while talking on the phone  Research is now calling this task switching  Field dependent behavior- distracted by and acting on an irrelevant impulse that interferes goal directed behaviors6   Use of systematic training incorporating a series of tasks with progressively increasing attentional demands has resulted in improvements in attention to tasks and therefore memory  Need to attend to remember!  Gradually increase attentional demands of activities through choosing activities with longer duration and additional distractions  Downgrade->Upgrade Attention  Reduce environmental distractions  Upgrade as able Intervention  Educate client regarding self pacing and modification strategies  Address awareness of the impairment  Ex: limit background noise, turn off phone, set timer for when you can take a break from the task, record notes for internal distractions  Prescription of psychostimulants (methylphenidate from MD)   Meta analysis comparing: (Park and Ingles, 2001. Pedretti text.)  Direct retraining of the damaged cognitive function or direct cognitive retraining  Intervention is based on a series of repetitive exercises or drills in which clients respond to visual or auditory stimuli  Did not significantly affect outcomes  OT Session: “Memorize these pictures of household items to improve your attention for cooking.” Attention  Having clients learn or relearn how to perform specific skills of functional significance (specific skill training) Intervention  Intervention is trained either concurrently with or in the context of the specific skills  Premise is that through carefully structured practice of a specific skill that is impaired as a result of brain damage, it is possible for individuals to compensate and develop alternative neuropsychological processes that rely on preserved brain functions  Client can learn to perform the skill in a way that is different  This approach applies behavioral principles and an understanding of how the impairment in attention affects various skills.  Overall performance improved in 69% of the participants who received specific skills training. Medium to large effect size.  OT Session: “Cooking seems challenging now due to your distractibility. Let’s go into the kitchen and prepare a meal while we try out some strategies that can make you more successful.”   Time pressure management (TPM)  Teach clients to give themselves enough time to deal with real-life tasks.  Also includes:  Enhance awareness of errors and deficient performance. Self instruction training. Planning and organization. Rehearsing task requirements. Modifying environment. Strategy of “Let me give myself enough time.”  OT Session: “In today’s session you’re going to cook a new recipe you’ve been wanting to try. While cooking, you’re going to utilize some TPM strategies.”  Self-instruction statements  Statements are utilized to improve listening and ask for repetition if attention strays. Attention  “To really concentrate, I must look at the person speaking to me.” “Although it is not horrible if I lose track of a conversation, I must tell the person to repeat the information if I have not attended to it.” Intervention  OT Session: “Today we are going to take some drink orders of the other therapists and then make their drinks in the kitchen. Let’s utilize self-instruction statements to help complete this task.”  Self-management strategies  Orienting procedures  Clients ask themselves orienting questions at various intervals (“What am I currently doing?” “What am I supposed to do next?”).  Pacing  Build in breaks to the task, self monitor fatigue and attention  Key ideas log  Clients are taught to write or record questions/ideas to address later so that the task is not interrupted  OT Session: “During the session, you will be working on an Excel spreadsheet to simulate your work tasks. Let’s review some self-management strategies that you can use while working on this task.” Memory  Attention -> Encoding ->Storage -> Retrieval  Attention- processes that allow a person to gain access to and use incoming information  Brainstem, thalamic structures, frontal lobe  Encoding- how memories are formed, an initial stage of memory that analyzes the material to be remembered (visual vs verbal Memory characteristics of information)  Dorsomedial thalamus, frontal lobes, languages systems, visual Terminology system  Storage- how memories are retained, transfer of a passing memory to a location in the brain for permanent access  Hippocampus, BL medial temporal lobes, prefrontal cortex  Retrieval- how memories are recalled, searching for existing memory traces  Frontal lobe   Short term memory (STM)- storage of limited information for a limited amount of time  Ex: Remembering the specials that were just told to you at a restaurant for a brief time period  Working memory- related to STM and refers to actively manipulating a limited amount of information in short term storage via rehearsals  Ex: Dividing up a dinner bill among 6 friends after adding in 20% tip (all mental math) Memory Terminology  Long term memory (LTM)- relatively permanent storing of information with unlimited capacity  Implicit/Nondeclarative/Procedural- an unconscious form of LTM; how to perform a skill, does not require conscious retrieval  Ex: Driving  Explicit/Declarative: a conscious form of LTM; facts that were learned  Episodic memory- autobiographical events/experiences, personally experienced events  Ex: HS graduation, 21st birthday  Semantic memory- facts/concepts/knowledge of the general world  Ex: Names of presidents, dates of holidays  Memory Terminology   Most promising interventions to improve function in those with memory deficits rely at least partially on compensatory techniques.  When choosing a compensatory technique consider the following: Memory  Severity of injury Intervention  Severity of the impairment in memory  Presence of comorbid conditions (physical, language, cognitive)  Social supports  Client’s needs (what occupations will it be used with, what environment, etc.)   Most promising interventions to improve function rely partially on compensatory techniques  Techniques such as memory drills have been unsuccessful in terms of generalizing to meaningful activities  May be a change on a laboratory based measure without corresponding to change in daily function  Memory Notebooks/Technology  Utilizes learning theory and procedural memory skills Memory (procedural memory skills may be preserved in many clients with severe memory impairments) Intervention  3 stages:  1) Acquisition or how to use it  2) Application or where and when to use it  3) Adaptations or how to update it and use it in novel situations  WSTC Strategy (addresses self-regulation and self-awareness)  W: What are you going to do?  S: Select a strategy for the task.  T: Try out the strategy  C: Check how the strategy is working.  Needs reinforcement for client to continue to use it   Errorless Learning  Errorless learning is a learning strategy that is in contrast to trial and error learning or error-ful learning.  Client is NOT given the chance to make a mistake (so therefore no mistakes to remember)  Found to be a better technique for individuals with severe memory impairments  People with memory impairments typically remember their mistakes but not the correction  It is typical for people with memory impairments to remember their Memory own mistakes more successfully than they remember the corrections to their mistakes occurring via explicit means (e.g., a Intervention therapist's cue)  In other words, people may remember their mistakes but not the correction , therefore don’t let the mistake happen (intervene before it occurs)  With errorless learning a person learns something by doing it (procedural memory), rather than being told or shown by someone.  In addition, the person is NOT given the opportunity to make a mistake (i.e., there are no mistakes to be remembered)  The hypothesis is that reduction or prevention of incorrect responses facilitates memory performance   Assistive Technology Memory Intervention  Mnemonics  Any strategy used to remember something  Includes rhymes, poems, acronyms, chunking and imagery techniques  How did you memorize cranial nerves, the carpal bones?  Shown to be best suited for remembering specific and limited types of information (Example: name of staff members)  More research needed to see if this strategy is generalizable to untrained tasks  OT Session: “Your new home health aid’s name is Nancy. Nancy helps you with dressing to keep you Fancy!”   Rehearsal strategies  The repetition of information  Used with spaced retrieval where the client is asked to recall the information with increasing time intervals  For motor based recall, utilizing procedural memory  WOPR Memory  W: Write  #1 memory strategy!! Intervention  O: Organize  P: Picture  R: Rehearse  Temporal tags  Focusing on when and where the event to be remembered occurred  Ex: Where did I park my car? Executive Functioning   “Those functions that enable a person to engage successfully in independent, purposive, self-serving behavior.”  Decision making, problem solving, planning, task switching, modifying behavior in light of new information, self- correction, generating strategies, formulating goals, and sequencing complex actions.  EF is better assessed and demonstrated with novel tasks or familiar tasks with unexpected incidents Executive  Prefrontal and frontal areas. Functioning  Dysexecutive Syndrome  Impaired judgement, impulsiveness, apathy, poor insight, and lack of organization, planning and decision making.  Along with behavioral disinhibition  May do well on pen and paper tasks but “catastrophic” problems in situations requiring multitasking and planning.   Metacognitive training  Understanding- recognize the deficits  Use tasks that will show deficit  Practice- rehearse specific strategies that the OTP and client identify together need to be learned and practice  For example, using the pacing strategy  Client thinks about what particular strategy or method will Executive best fit the task demands  Transfer-consider when and where these strategies Functioning could be applied in real life occupations/contexts Intervention  Other appropriate interventions include TPM (from attention), self-instruction training, WSTC strategy (from memory), external cuing devices, and manipulation of environmental variables with a focus on level of distraction.1   Problem solving training  Interventions include: stop and think; asking clear questions; define the problem; evaluate and examine alternative situations; emotional self-regulation.  Reinforced by role-playing and practicing real-life demanding situations.  OT session: “Hmm it looks like you’re stuck on how to make a reservation on this website. Let’s stop and think to see if you can complete the reservation”  Goal management training Executive  Aimed to decrease disorganized behavior and improving ability to maintain intentions in goal-directed behavior. Functioning  Five steps are taught using errorless techniques and cues are gradually faded to ensure nearly perfect performance. Intervention  1: Orienting and assessing the current situation  Direct awareness to task  2: Select the main goal  3: Partition the goals and make sub-goals  4: Rehearse the steps necessary to complete the task  Encode, rehearse, and retain goals and sub-goals  5: Monitor the outcome  Compare the outcome of action with the stated goal  OT session: “Let’s work on your ability to complete your morning routine. We will go through these five steps and I will provide verbal assistance as needed to ensure error free performance. We will use this system every day during your ADL session and over time you won’t need as much assistance!” Topics in Cognition   Challenging to administer assessments and intervene due to time constraints  However, a documented cognitive impairment that impacts FUNCTION and SAFETY can enhance the client’s chances of receiving proper care!1  Acute care: Main role is determining discharge environment and next level of care Acute Care Karmali, S., Hagstrom, L., Mah, K., Mishima, G., & Seminary, J. (2018). Functional cognitive assessment and intervention in acute care. SIS Quarterly Practice Connections: A Supplement to OT Practice, 3(4),  Acute Care Karmali, S., Hagstrom, L., Mah, K., Mishima, G., & Seminary, J. (2018). Functional cognitive assessment and intervention in acute care. SIS Quarterly Practice Connections: A Supplement to OT Practice, 3(4),   The goal of occupational therapy with people with dementia is to emphasize remaining strengths, maintain physical and mental activity for as long as possible, reduce caregiver stress, and keep the individual in the least restrictive setting for as long as possible.  Key features of interventions addressing cognition include metacognitive and domain-specific strategy instructions, task-specific training, and environmental modifications.  There is no single approach to dementia, and practitioners should evaluate current research while prioritizing valued occupations to enhance participation and meaningful engagement.  Communication  Wandering  Avoid reasoning with the client.  Assess and address the reason for wandering.  Listen.  Provide signs in the environment for cueing (e.g., stop sign).  Offer choices when possible.  Use distraction techniques to interrupt pacing (e.g., familiar Dementia & pictures on the wall).  Decrease demanding social situations  Provide opportunities for activities and movement, walk with  Provide visual cues client and keep areas uncluttered and safe Behavioral  Monitor fatigue, fluid intake.  Sundowning behaviors: an increase in activity and  Monitor the client’s feet wounds, including cuts, lacerations, often agitation that begins in the late afternoon and bruises. extends into the evening or night. Intervention  Use a Medic Alert identity wristband.  Simplify interactions and the environment during sundowning.  Provide reassurance, attentiveness, and acceptance  Use adequate lighting as shadows can create s confusion.  Pillaging, rummaging, and hoarding  Learn the client’s favorite hiding places.  Provide a safe area for physical activity during the day.  Give the client a familiar item to hold.  Provide reassurance in a calm and caring manner.  Involve the client in valued occupations that involve sorting items.  Provide the client with fluids during the day to  Provide the client with rummaging closets or areas. reduce the cognitive changes brought on by dehydration.  Do not scold, tease, or punish the client or respond with anger.  Reduce noise and clutter.  Modify the environment to be more engaging (e.g., fish tank).  Anger  Activities and occupations  Anticipate problems and stressors.  Focus activity on the client’s interests and abilities, not  Rephrase negatives as positives. limitations.  Provide the client with a sense of belonging.  Ensure the client isn’t hungry, thirsty, tired, or experiencing pain.  Promote appropriate verbal and nonverbal communication and positive behaviors.  Simplify tasks and allow time for response. Reduce stimuli in the environment.  Provide activities that are meaningful, safe, modifiable and adaptable, routine, pleasurable, and dignified.  Dementia & Behavioral Intervention s Bresley, J., Gunesch, A., & Foidel, D. (2022). New dementia care tool benefits   Affective functioning  Teach relaxation activities.  Social functioning  Educate caregiver on  Refer to structured appropriate medication intake. socialization.  Refer to structured and  Encourage intergenerational planned socialization (e.g., activities. adult day care center).  Use structured verbal and  Encourage structured nonverbal communication activities (e.g., leisure techniques. Dementia interests with family or caregivers).  Use reminiscence therapy. Intervention  Facilitate movement and  Sleep functioning  Promote physical activity exercise, and s intergenerational activities. during the day, and  Facilitate spiritual expression encourage the client to be activities. outdoors in the sun, as appropriate, to maintain  Sensory–perceptual their internal clock. functioning  Reinforce appropriate sleep  Assess and integrate sensory patterns through good sleep functioning and processing hygiene and routines. abilities.  Ensure the client has appropriate physical aids (e.g., hearing aids, glasses).  Environmental interventions, used in conjunction with other approaches  Home Modification Focus  Dementia Enabling Environ Sensory–perceptual ments | Alzheimer’s WA modifications: appropriate  Some recommendations: lighting; high-contrast  Covering/removing mirrors coloring or textured Dementia & surfaces; objects for  Motion sensor lights  Color contrast (light stimulation; varied, safe, Environmen and tactile objects; visual switches and doorknobs to walls) tal blocks Memory enhancement:  Remove bathroom door  Cover doors (if wandering is Modification large-print calendars, daily schedules, seasonal a concern)  Curtains drawn during day/ s decorations, use familiar furniture, photographs, Blackout curtains at night  Remove door locks  Cover sockets favorite music, notices of  Water temperature control current events  Remove tub doors Structured common areas  Play enjoyed music from A consistent and calm younger years environment  Recognizable furniture Inconspicuous locks on cabinets and doors,   Care Partner Involvement  Identify the care partner  Draw in the care partner with dementia- specific questions and knowledge Dementia &  Caregiver training serv ices | AOTA Caregivers  CMS Announces Medic are Dementia Care Mo del | AOTA  Guiding an Improved D ementia Experience (G UIDE) Model | CMS  Provide hands on Burch, K. & Cigliana, J. (2018). Engaging a care partner in interventions for persons with dementia. SIS Quarterlytraining Practice aimed at Connections: A Supplement to OT Practice, 3(4), 14-16. the most frustrating  Dementia & Caregivers New codes support reimbursement for caregiver training | AOTA   Errorless learning  Repetitive training in correct performance of cognitive tasks (familiar tasks!)  Strong evidence supports the use of error reduction strategies to enhance performance of daily activities  Cognitive stimulation Alzheimer  Wide variety of activities to engage the mind  Moderate evidence for improving social interaction and quality of life Disease  No benefit to ADLs  Cognitive training Intervention  Specific practice of cognitive tasks  Mixed evidence s  No benefit on ADLs (Level 1 RCT)  Large effect size for compensatory and restorative cognitive training for improved ADLs (Level 1 RCT)  Reminiscence Interventions  Activities to remember past events  Mixed evidence  No support on quality of life (Level 1 systematic review)  Differences on measures of cognitive function, affective function, and Smallfield, S. & Syrovatka, C. (2018). behavior DURING therapy (Level 3 study) AOTA critically appraised topic series: Alzheimer’s Disease. SIS Quarterly Practice Connections: A   ADL training and activity modification to improve OR maintain performance  Errorless learning and prompting strategies to improve ADL performance  Ambient music and multisensory interventions to improve short-term behavior  When does the client need improved behavior in their routine? Alzheimer  Exercise based interventions to improve OR maintain ADL performance Disease (functional mobility and sleep)  Are there challenges with mobility and sleep? Intervention  Monitoring devices to prevent falls in the home  Beneficial for both client and care provider s  Communication skills training to promote caregiver quality of life and well-being  Not arguing with client, but redirecting  Psychoeducational interventions to improve caregiver wellbeing  Education, skill training, coping strategies  Managing Behavior Changes  Managing Sexually Inappropriate Behaviors Piersol, C.V., Jensen, L., Lieberman, D., & Arbesman, M. (2018). Evidence connection- Occupational therapy interventions for people with Alzheimer’s disease. American Journal of Any Questions?