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“Cognitive Impairment and Therapy: Taking Advantage of Existing Abilities to Maximize Outcome”

Presented by: Robert G. Winningham - B.A (Psych), M.S. (Psych), Ph.D. (Neuroscience)

Will commence LIVE from Monmouth, OR at 5pm PDT US

Andrew Ellis BSc (Ex. Sci), M. Phty

World Health Webinars (USA) Host

Rehabilitation physical therapist

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Dr. Rob Winningham

• Professor and Chair of Psychology Division - Western Oregon University (WOU) where he manages the Psychology and Gerontology Departments

• Ph.D. in Neuroscience from Baylor University

• 20 years of experience researching applied memory issues

• Published many peer-reviewed articles in the area of human memory

• Makes frequent tv and radio appearances giving well over 500 invited presentations about memory and aging at various conferences and workshops.

• Author of Train Your Brain: How to Maximize Memory Ability in Older Adulthood

• Co-Director of Geriatric Wellness Center

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© 2013, Dr. Rob Winningham All Rights Reserved

Table of Contents

Understanding how memory changes with dementia and aging

• Executive functioning

• Memory (many different types and functions)

Improving memory and cognition

• For people who can make new memories

• For people who cannot make new memories

• Short term and long term strategies

Behavior management strategies


We Must Start with Executive Functioning

Executive functioning is an umbrella term that includes:

• Attention (sustained, selective, alternating, divided)

• Inhibition -- prevents us from just responding to the environment, rather than executing plans.

• Problem solving

• Monitoring tasks

• Planning

• Mental flexibility


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Executive Functioning

The ability to pay attention to the appropriate stimuli will improve people’s ability to learn

“A clear and robust relationship between executive functioning and memory is evident” (Duff et al., 2005)

Duff et al. (2005) reported that memory ability and executive functioning have over a 50% overlap.

Executive functioning predicts cognitive and activities of daily living (ADL) outcomes (Vaughn & Giovanello, 2010)


Prefrontal Cortex

Public Domain Image from:

http://en.wikipedia.org/wiki/File:Prefrontal_cortex.png


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Dorsolateral Prefrontal Cortex

Involved in:

working memory

response inhibition

abstract thinking

problem solving

maintaining

shifting set


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Orbitofrontal Prefrontal Cortex

Involved in

impulse control

monitoring ongoing behavior.

Lesions are associated with

impulsivity

aggression

sexual promiscuity

antisocial behavior


Remember Phineas Gage?


Frontal Lobes

Many problems associated with aging and an impaired ability to be attentive and learn new information can be linked to the frontal lobes

Frontal lobes help people attend to what is important and ignore irrelevant stimuli

An inability to ignore irrelevant stimuli will further reduce cognitive resources


Inhibition

Inhibition and attention are very similar processes

• Antisocial behavior (see next slide)

• Social behavior

• Off-target verbosity


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Frontal Lobe Inhibition

Murderer’s Brain Normal Brain


Off-target Verbosity

A lack of inhibition can be seen in speech patterns. Off-target verbosity is characterized by speech that lacks focus and coherence.


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On-target Verbosity

In response to the question, “How much education did you get?”, an on-target response would be:

“I finished high school and then a bit of college.”


Off-target Verbosity

An off-target response would be:

“Well, let’s see. I went to school in _____ where, uh, uh, I grew

up in ______. Back in those days, why, they didn’t have the big high schools that they have now. When I went back there a few years ago in…uh, I don’t remember exactly when it was. I think it was the summer of 1980 or maybe it was 1981. I went for my brother’s 50th anniversary and I didn’t recognize the place at all. We went to a small school, the only school in town. It was the only place to go. All the children were in one room. The school only went to grade 9 or uh, uh, I think it was…was it grade 9? No, it was only grade 8 because _____ (neighbor’s daughter) left to go to nursing school and she had to go to _____ to finish Grade 9. She never finished nursing anyway. She got married but it didn’t last long.”


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Do you want to feel what it is like to have a hard time inhibiting?


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.


READY?

© 2013, Dr. Rob Winningham All Rights Reserved © 2013, Dr. Rob Winningham All

Rights Reserved

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© 2013, Dr. Rob Winningham All

Rights Reserved

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Inhibiting and filtering in life

Why does the Stroop Effect occur?

Your residents experience something similar to the Stroop Effect when they have difficulty inhibiting automatic or procedural behaviors?


Frontal lobes: Impulse control problems

What automatized behaviors do residents with dementia have a difficult time inhibiting?


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Postural tendencies: lifting, crossing legs (THR)

Waiting for all of the instructions

Shoveling food

Not cutting up food in small enough pieces

Getting up with no one around or without device

Bending over

Hurrying to the bathroom

Premorbid gait deviations

Inappropriate social behavior

Inappropriate laughter

Farmers and outdoorsmen urinate in courtyard



Saying answers before the right time

Getting started before all the instructions have been given

Can’t stop working on the previous task

Emotional perseveration

Keep saying the wrong answer each time a certain question is asked

Sexual or socially inappropriate behavior

Off-target verbosity

Picking your nose


How can you help residents process information at a deeper level?

Predictions

Postdictions

Retention testing that is announced beforehand

Spaced retrieval works! See Sumowski et al., (2010)


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There’s an app for that


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Put the question here


After a period of time an alarm will go off. If they

answer correctly, press the green check.


Then, the interval will double.


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How can you help residents process information at a deeper level?

Mental imagery

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.


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Multiple Approaches

The previous approaches to enhance attention can be done in the moment, when trying to get a resident to make a new memory.

There are other strategies to enhance executive functioning over a longer period of time.


Enhance Executive Functioning

We can enhance executive functioning (Miotto et al., 2009), which should improve many patients’ prognoses and residents’ ability to stay independent longer.

Executive functioning is the key to the all important question of whether improvements will generalize to everyday situations.


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Ways to Enhance Executive Functioning

Reduce Stress and Anxiety

• Acute effects

• Long-term effects



Mindfulness meditation training

• Zeidan et al (2010) found that mindfulness meditation training improved executive functioning (and working memory capacity).



Physical Exercise

Cognitive Exercise

• Attention activities

• Inhibition activities

• Social interaction



Kramer et al. (2001) found that participating in a six month walking program led to increased attention in 60-75 year old adults.


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Exercise and Cognition

Colcombe and Kramer (2003) reported the results of an 18-study meta-analyses 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)


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Colcombe and Kramer (2003) found that a number of variables are related to the amount of improvement associated with exercise, including

Age [Older (66-70 or 71-80) > Younger (55-65)]

Gender (F > M)

Type of exercise (Aerobic + Strength > Aerobic)

Length (6+ months > 5 or less months)



The ability to pay attention to relevant stimuli is correlated with cognitive ability in older adults. It appears that exercise affects this ability.



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


What type of exercise is best?

A mixture of aerobic and strength (or resistance) training is best.


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.


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Cognitive stimulation


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There are a lot of cognitive stimulation options

Paper and pencil programs

Computer-based programs

iPad programs

Certified Cognitive Stimulation Instructor Program (email me for details, if you are interested)


Many Resources Available for Cognitive Stimulation

Activity Connection

• I will give you a pw at the end of this presentation

• http://www.activityconnection.com/store/cognitivestimulation/


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Taking Advantage of Cognitive Abilities that are Retained with Dementia

Understand memory

Understand how memory and cognition change

What is retained and how can we take advantage of that?

Behavioral management ideas


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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 15 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?


Memory

The words at the beginning of the list were well remembered (primacy effect) and the words at the end of the list were well remembered (recency effect). Why?


This Can Inform Us About Why We Sometime Forget

The first words (primacy effect) were rehearsed more and made it into long-term memory.

The last words (recency effect) were recalled at a higher rate because they were still in short-term memory (immediate or working memory).


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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

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Order in Which Words Were Read

Pro

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Series1

Series2


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Why did the recency effect go away with a delay?

The new information (i.e., generating new words that start with a certain letter) displaced the last words, from the to-be-remembered list, out of short-term or working memory.


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).


This Can Inform Us About Why We Sometime Forget

The last words, from the no delay condition, were recalled at a higher rate because they were still in short-term or working memory.

The first words, in both condition, 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


A Great Memory Model

How do humans learn and make new memories?

The Modal Model of Memory helps explain how we make new memories.


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The Human Capacity to Learn


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 long-term memories is affected.

• Retrogenesis


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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.

However, storage and retrieval of old memories might be affected with more advanced dementia, usually following retrogenesis.


Three Types of Memory

Procedural – anoetic, implicit, nondeclarative, automatic

Semantic - declarative, explicit

Episodic - autobiographical


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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

© 2013, Dr. Rob Winningham All Rights Reserved © 2013, Dr. Rob Winningham All Rights Reserved

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The ability to make new procedural memories is huge!

Creating new procedural memories requires “errorless learning” and is used when people can’t make new memories.

• Sequencing

• Routine

• Family members involvement


What Abilities Are Preserved (to some degree) in People with Dementia?

Crystallized intelligence (knowledge, wisdom?)


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


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What Cognitive Ability Connects These Co-occurring Symptoms Seen with Dementia?

Depression

Anxiety

Paranoia

Inappropriate social behavior

Anger

Emotional perseveration


Behavioral Management

This is to be expected

The behavior and thoughts are often analogous to a child’s behavior (remember retrogenesis)

• Lack empathy

• Lack awareness

• They often don’t see how their behavior is affecting others

• Arguing or reasoning while they are agitated doesn’t work



Use non-threatening postures, don’t tower over them

• Eye level

• Clean glasses

Monitor your emotions and subtle body language and facial expressions.

Help the staff, give purpose (name badge?)


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Redirecting

• Photographs

• Music (customize, teenage years?)

• Audio files

• Videos (on iPad or iPhone?)

• Help caregivers fold laundry or do other tasks (purposeful behavior)



Live in the moment

• We don’t do reality orientation therapy anymore

• We try not to argue

• We try not to escalate

• Maybe it is ok to deceive, if it improves quality of life?



What are the triggers?

• Overstimulation?


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Physical exercise might help. Nagamatsu et al. 2012 reported that twice weekly resistance training led to improvements in cognition.

Exposure to direct sun light might help sleep and night/day orientation



Music therapy has been shown to decrease aggression and anxiety in dementia residents.

Lavender aromatherapy (spray bed linens)

Other ideas?


Contact Information

Dr. Rob Winningham

Psychology Division

Western Oregon University

345 N. Monmouth Ave

Monmouth, OR 97361

Email: [email protected]

http://www.activityconnection.com

Username: prime87

Password: actcon321


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mailto:[email protected]

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