Objectives Unders tand the bene f i t s o f cogn i t i ve s t imu la t ion

for t h e PACE p op u la t ion

Identify how simple activities can become cogn it ively- s t im u la t in g

Attendees wil l be able to implement CAP at their PACE s it e t h a t w ill en h an ce cen t er act ivit ies t o be cogn it ively- s t im u la t in g

Six Areas of Cognition

Stages of Cognitive Impairments

Neurocognitive Disorder (NCD)

Early Stage Late Stage

Mild Cognitive Impairment (MCI)

Difficulty with problem solving Difficulty sequencing

Normal AgingMild memory loss/Word finding

difficulty Decreased processing speed

Dementia vsNeurocognitive Disorder

Prev ious ly re fe r red to as “dement ia ” accord ing to t h e Diagn os t ic an d St a t is t ica l Man u a l of Men t a l Disor der s , 4 t h Ed it ion (DSM- 4 )

DSM- 5 t er m focu ses on a declin e, r a t h er t h an a deficit

Less s t igm at ized

Can u se t er m s in t er ch an geably

Does MCI always turn into NCD?● Not a l l t hose w i th MCI w i l l p rog ress to NCD

● St u d ies su gges t t h a t 10 - 20 % of t h ose aged 6 5 an d older m ay h ave MCI.

● 20 - 4 0 % of t h ose w it h MCI w ill p r ogr es s t o NCD

● T h i s i s a g r e a t o p p o r t u n i t y f o r i n t e r v e n t i o n !

(Alzh eim er ' s Associa t ion , 20 16 ) (Rober t s & Kn op m an , 20 13)

Global Deterioration Scale for Dementia

Useful, quick standardized assessment for p p t sw it h dem en t ia / NCD

Determines clinical stage or level

Help to document the progression of dement ia w it h cor r esp on d in g s t ages

M a t c h t h e e n v i r o n m e n t a l s t i m u l i t o t h e p p t scogn it ive level t o m axim ize beh avior a l r esp on ses

Global Deterioration Scale for Dementia

● The process:● check l i s t /observa t ion / tes t ing / repor t , as to the

advancem ent of the ppt ’ s dem ent ia (see handout )

● Stages 1 - 4 (Ear ly/ M od Dem ent ia)● new learn ing capaci t y● i dea l fo r the rapy !

● Stages 4 - 6 (Late Stage)● best in tervent ion would be sensory st im ulat ion

Why is Cognitive Stimulation Necessary for Our Population?● Keep ppts in thei r hom es and as independent as

possible

● Evidence- based act ions that can slow decl ine in th ink ing funct ions: ● Exercise ● Cont ro l ca rd iovascu la r r i sk fac to rs ● Par t ic ipate in menta l ly s t imula t ing and soc ia l ly

engaging act ivi t ies● Supplements (e .g . f ish o i l )

PACE Philosophy● “A PACE p rogram i s ab le to p rov ide the en t i re

cont inuum of care and services to sen iors w i th chron ic care needs whi le m ain tain ing thei r i n dependence in t h eir h om e for a s lon g as p oss ib le”

● S e e m o r e a t : h t t p : / / w w w . n p a o n l i n e . o r g / p o l i c y-advocacy/ va lu e- p ace# p h ilosp h y

Why Perform Cognitive Activities in the Day Center and Not in

Therapy?● Peer in te rac t ion● Socia l iza t ion● Not possible to see 200 ppts for M CI● More e f f i c ien t use o f t ime and space● Already do ing act iv i t ies● Not a l l PACE p rograms have on s i te the rapy● Cost e f f i c ien t – therapy is expensive! ☺

EvidenceLink to neuroplasticity

• “Use it or lose it”• Failure to drive specific brain functions can lead to

functional degradation• Promote reorganization of remaining tissue in the

damaged brain

(Kleim & Jones, 2008)

Evidence●Par t i c ipan ts t rea ted in sma l l g roups w i th cogn i t i ve

st im ulat ion act ivi t ies (baking, indoor gardening, word gam es, m usic, etc.)

●Ppts who received cogni t ive st im ulat ion in tervent ions scored sign i f icant ly h igher in cogni t ive funct ion tests

● Find ings suggest cogni t ive s t imula t ion has a benef icial ef fect on m em ory and th ink ing for individuals w / dem ent ia

(Woods, Agui r re, Spector , & Or rel l , 2012)

Evidence

Cogni t ive Rehabi l i t at ion

Cogn it ive Tr a in in g

Cognitive Stimulation

(Hop p er , Bou r geois , Pim en t el, Qu a lls , Hickey, Fr ym ar k , & Sch oolin g , 20 13)

The Cognitive Activity Program (CAP)

● Implement group act iv i t ies that w i l l be menta l ly chal lenging, yet rem ain w i th in the Zone of Proxim al Developm ent (ZPD)

● St imu la t ing func t iona l ac t i v i t i es fo r regu la r cogni t ive exercise

● Promotes par t ic ipat ion and soc ia l iza t ion among par t icipants

(Vygotsky, 1978)

Who is the CAP program for?● Everyone!

● Mi ld cogni t ive impai rment● Early and Late stages NCD/ dem ent ia

● Tasks can be modified to target lower level ppts● I nc rease p rompt ing● Such as asking yes/no questions, instead of

open ended quest ions m eant to prom ote conversat ion and problem solving

CAP Process

Write proposal to center director

MCI Activity What ’ s Wr ong w i th t h i s Photo?

Object i ve: Im prove at tent ion, verbal expression, reasoning, predict ion, social izat ion, and par t icipat ion

Example questions: W h y d o y o u t h i n k t h i s h a p p e n e d ? I s t h i s d a n g e r o u s ? W h a t m i g h t h a p p e n ? What do you th ink the pe r son /an imal was

t h in kin g? Have you ever seen something l ike this before

Feedback● Need m ore picture based sl ides, less focused on

language, to accom m odate bi l ingual ism

● Use the la rges t fo rmat poss ib le fo r v i sua l l y im pai red

● Pr in t ou t p i c tu res and p lace in b inder fo r ppt ’ s to use in sm al l groups or individual ly in downt im e

● The ppts asked for M ORE TIM E and M ORE SLIDES because the en joyed the ex so m uch!

MCI/Early Dementia ActivityCook ing Video/ Act i vi t y

Object i ve: Im prove m em ory recal l , sequencing, at tent ion to detai l , verbal expression, reasoning, predict ion, social izat ion, and par t icipat ion

Example Questions What is your favori te food? W h a t i s y o u r l e a s t f a v o r i t e f o o d ? What do you l ike to cook? Recal l the s teps , provide 2- 3 ch oices if u n able

t o gen er a t e r esp on ses

Feedback Ppts s t a t ed t h ey w ou ld like t o t h e m ake t h e r ecip e

t h e sam e day t h a t w e w a t ch ed t h e video Difficulty with scheduling a video and cooking

act ivit y in t h e s am e day

Early StageDementia Activity

Coupon Hun tObject i ve: To create a fun learn ing exper ience, m ost

have no idea what th ings cost these days. Targets at tent ion, coordinat ion, fol low ing di rect ions, problem solving, language, categor izing, and sequencing sk i l ls

E x a m p l e i t e m s t o s e a r c h f o r : milk lotion deodorant coffee filters

Feedback● Difficult to collect newspapers and coupon. The

dept needs to prepare ahead of t im e● Need multiple copies of the same coupons so ppts

don’ t f ight over coupons● Even if ppts don’ t do thei r own physical shopping

( i .e. hom e care per form s the task), they can st i l l t ake back par t of the process by cut t ing coupon

● Schedul ing conf l ic ts wi th ppts going hom e

Late Stage Dementia ActivitySensor y Bin

Object i ve: Im prove sensory percept ion/ stereognosis, at tent ion, social izat ion, verbal expression, rem in iscing, plann ing, and reasoning

Possible Themes: Seasons Holidays Soft

Feedback● The Ac t i v i t i es dep t had p rob lems i n the pas t w i th

ppts eat ing the r ice and c/ o di f f icul t y clean ing up the act ivi t y

● Requ i res 1 :1 superv i s ion fo r ppts w i th advanced NCD/ dem ent ia to help:● I n i t i a t i on o f task● Faci l i ta te naming, count ing, categor izat ion● Safe ty w i th sma l le r i t ems

Late Stage Dementia ActivityLaundr y

Object i ve: Im prove hand- eye coordinat ion, sensory percept ion, at tent ion to detai l , verbal expression, sequencing, problem solving, social izat ion, and par t icipat ion

Possible fabrics: silk cotton wool nylon

Feedback Frame act iv i ty by ask ing for he lp fo ld ing laundry

t o m ot iva t e p p t s

Use baby clothes! Very motivating and helped with r em in iscin g an d exp r es s ive lan gu age

A c t i v i t i e s d e p t r e p o r t e d t h a t t h i s w a s v e r y u s e f u l i n m in im iz in g w an der in g of p p t s w it h advan ced dem en t ia .

Lessons in Developing CAP INTER - DISCIPLINARY COMMUNICATION is KEY

t o m akin g a ll of t h ese act ivit ies su cces s fu l! U s e t h e c h a i n o f c o m m a n d ( i . e . s u p e r v i s o r f i r s t )

in a ll com m u n ica t ion

S t a r t e a c h a c t i v i t y b y s t a t i n g t h e c o g n i t i v e s k i l l s bein g addr es sed This will help to inform staff an d ppts abou t t h e

object ive of t h e ex

Tra in CNAs and Rec Coor d in a t or s t o con du ct act ivit ies in dep en den t ly w it h ap p r op r ia t e p r om p t s

Nearly any activity can be cognitively stimulating, if you create objectives for cognitive

stimulation ahead of time focused on the 6 major areas

of cognition

Points to Consider When Conducting Activities …

Be purposeful with your promptingAsk open ended questions to

promote languageUse hand-under-hand prompting if

necessary … We want our ppts to dothe activity, not just be observers

Future Directions● Admin is ter Global Deter iora t ion Scale to a l l

par t icipants

● Assign ppts to groups based on thei r level

● Act i v i t i es tha t a re ca te red to ppts level

● Dosage/ In tens i ty should match the sk i l l leve l

● Fur the r research !

Take Away Points• Ind iv idua ls w i th MCI and ear l y s tages o f

dem ent ia have new learn ing abi l i t y and can benef i t f rom cogni t ive t reatm ent

• Impor tan t to de te rm ine wh ich s tage o f dem ent ia the person is in to asses new learn ing abi l i t y

• Don’t be discouraged by ppts w i th cogni t ive im pai rm ent !

Contact Us!

Suzy Newby –su zy.n ew by@ gen es ish cc.com

Cam m y Law lor –cam ar in .law lor @ gen es ish cc.com

ReferencesAlzheim ers Associa t ion . Mild Cogn it ive Im p a ir m en t (MCI) Sign s , Sym p t om s , &

Diagn os is . (n .d .) . Ret r ieved Au gu s t 16 , 20 16 , fr om h t t p :/ / w w w .a lz .or g / dem en t ia / m ild - cogn it ive- im p a ir m en t - m ci.a sp

Hop p er , T., Bou r geois , M., Pim en t el, J., Qu a lls , C. D., Hickey, E., Fr ym ar k , T., & Sch oolin g , T. (20 13). An eviden ce- based sys t em at ic r eview on cogn it ive in t er ven t ion s for in d ivid u a ls w it h dem en t ia . American Journal of Speech-Language Pathology, 22(1) , 126 - 14 5.

Kleim , J. A., & Jon es , T. A. (20 0 8 ). Pr in cip les of exp er ien ce dep en den t n eu r a l p las t icit y: Im p lica t ion s for r eh abilit a t ion a ft er br a in dam age. Journal of Speech, Language, and Hearing Research, 51, S225– S239 .

Rober t s , R., & Kn op m an , D. S. (20 13). Clas s ifica t ion an d Ep idem iology of MCI.Clinics in Geriatric Medicine, 29(4 ) , 753- 772. doi:10 .10 16 / j.cger .20 13.0 7.0 0 3

Vygot sky, L. S. (19 78 ). Mind in society: The development of higher psychological processes. Cam br idge, MA: Har var d Un iver s it y Pr es s .

Woods , B., Agu ir r e , E., Sp ect or , A. E., & Or r ell, M. (20 12). Cogn it ive s t im u la t ion t o im p r ove cogn it ive fu n ct ion in g in p eop le w it h dem en t ia . Cochrane Database SystRev, 2.