strategies and techniques for cognitive rehabilitation · strategies and techniques for cognitive...

STRATEGIES AND TECHNIQUES FOR COGNITIVE REHABILITATIONManual for healthcare professionalsworking with individuals with cognitive impairment

Dr Michelle E. Kelly (D.Psych.BAT, BCBA-D)Dr Maria O’Sullivan (D.Psych.Sc., Clin Psych)

JULY 2015

1. Overview 3

2. Goal Identification 4

3. Guiding Principles 53.1 EffortfulProcessing 53.2 DualCognitiveSupport 53.3 ErrorlessLearning 5

4. Recall Strategies 64.1 Mnemonics 64.2 Cueing 64.3 Chunking 74.4 MethodofLoci 74.5 SpacedRetrieval 7

5. Specific Interventions 85.1 Face-nameRecall 85.2 NumberRecall 95.3 StoryRecall 105.4 List/ObjectRecall 105.5 ProceduralMemory 105.6 FluencyTraining 115.7 SemanticImpairments 12

6. Additional Support 146.1 MemoryAids 146.2 EnvironmentalAdaptation 146.3 Relaxation 14

7. Examples of CR in Practice 157.1 Case1–Number&Face-NameRecall 157.2 Case2–Face-NameRecall&ConversationalFluency 167.3 Case3–PlayingBridge 177.4 Case4–UsingthePhone&RepetitiveQuestions 18

Acknowledgements 19References 20

STRATEGIES AND TECHNIQUES FOR COGNITIVE REHABILITATION

ManualforHealthcareProfessionals WorkingwithIndividualswithCognitiveImpairment

STRATEGIES AND TECHNIQUES FOR COGNITIVE REHABILITATION 2

Disclaimer COGNITIVE REHABILITIATION MANUAL

No adviceThiscognitiverehabilitationmanual(“CRMANUAL”)containsgeneralinformationregardingcognitiverehabilitationstrategies.ThemanualhasbeenbycreatedbyTrinityCollegeDublinandTheAlzheimerSocietyofIreland(“AUTHORS”)duringthecourseoftheiracademicresearchcollaboration.The informationisnottobeconsideredascomprehensivemedicaladvice,andshouldnotbetreated assuchandshouldbeusedinconjunctionwithadditionalsupportingtherapieswherenecessary.

UseUseoftheCRMANUALisprohibitedunderthefollowingconditions:licensing,leasing,orselling theCRMANUAL,ordistributingtheCRMANUALforanycommercialpurpose.

Limitation of Warranties & LiabilityTheCRManaulcomes‘asis’,withnowarranties.Thismeansnoexpress,impliedorstatutorywarranty, includingwithoutlimitation,warrantiesofmechantabilityorfitnessforaparticularpurposeoranywarrantyoftitleornon-infringment.Theauthorsmakenorepresentationsorwarrantiesinrelation tothemedicalinformationcontainedwithintheCRManualtothemaximumextentpermittedby applicablelaw,theauthorsexpresslydisclaimall,andshallnotbedeemedtohavegivenanywarranties, expressorimplied(bylaworotherwise),inrelationtotheCRManualandtheuseoftheCRManual.

Professional assistanceTheCRMANUALshouldnotbeusedasanalternativetomedicaladvicefromanydoctororotherprofessionalhealthcareprovider.

Anyspecificquestionsaboutanymedicalmattershouldbeinconsultationwithadoctororother professionalhealthcareprovider.


Theaimofthismanualistopresenthealthcareprofessionalswithstrategiesandtechniquesthatcanbeusedtoassistpeoplewithmemoryproblemsinoptimisingmanagementoftheirdailylivesandactivities.Thesestrategieshavebeenincorporatedintogoal-orientedcognitiverehabilitationinterventionsthataimto(i)drawonretainedstrengthstosupportadaptivebehaviour;and(ii)achieveoptimumlevelsofwellbeingbytargetingperformanceonpersonallyrelevantgoals(Clare,2008).Themanualisnotacomprehensiveaccountofcognitiverehabilitation(CR)however,andshouldbeusedinconjunctionwithsupportingliterature(e.g.Clare,2008;Clare&Wilson,2004;Dunn&Clare,2007;Clareetal.,2010).

Thereareanumberofdifferentrehabilitativestrategiesoutlinedinthismanualaimedatassistingwithdifficultiesinmemoryandeverydayfunctioning.Generallyspeaking,thereisalotofindividualvariabilityinhowpeoplerespondtodifferentstrategies.Forthisreason,itispreferabletotryseveralstrategiesinanattempttodeterminewhatworksbestforeachindividual.

Asthehealthcareprofessional,yourroleistohelptheindividualunderstandhowtousethesestrategies,butthe individualisresponsibleforpracticeandimplementationbetweensessions.Explainthatthereisarequirement ofcommitmentandeffortontheirpart.Typically,you wouldidentifytargetareasorgoalstoworkon,practiseanumberofdifferentstrategies,andthendecidewhich strategiesthepersonprefersandcanusemostefficiently. Preferredstrategiescanbeselectedforadditionalpracticeuntiltheindividualfeelsconfidentusingthem.

Sessionsshouldbeconductedeitherintheperson’shome,orinacomfortablesettingsuitedtopractising theidentifiedgoals.Familymembers/carersshouldbe debriefedoneachsessionandprovidedwithexplanations ofstrategiesusedsothatthesemaybepractisedoutsideofinterventionsessions.

1. Overview

Rehabilitative Strategies and Interventions:

GUIDING PRINCIPLES RECALL STRATEGIES SPECIFIC INTERVENTIONS

EffortfulProcessingDualCognitiveSupportErrorlessLearning

Mnemonics CueingChunkingMethodofLociSpacedRetrieval

Face-nameRecallNumberRecallStoryRecallList/ObjectRecallProceduralMemoryFluencyTrainingSemanticImpairments


Difficultieswithmemoryorcognitioncanofteninterferewithaperson’sabilitytocarryoutspecifictasksoractivities;forexample,theabilitytorecallpeoples’names,playcards,orusehouseholdappliances.Insomecases,peoplemaynothaveanyspecificareaofconcern,butmaywishtoaddressmoregeneralmemoryproblems.Interventionscanthereforefocuseitherondirectreal-life,everydaysituationsoronmoregeneralrehabilitativeactivities.

Whereapersonidentifiesspecificgoalsthats/hewouldliketoworkon(e.g.relatedtotheexamplesprovidedabove),thetechniquesinthismanualcanbeappliedtohelpthepersontoaddressthesepersonalrehabilitationgoals.Insuchinstances,itcanbebeneficialtoassistthepersoninelicitinggoalseitherinformallythroughdiscussion,orbyusingstructuredgoal-settingapproaches,liketheBangorGoalSettingInterview(BGSI;Clare&Nelis,2012)ortheCanadianOccupationalPerformanceMeasure(COPM;Lawetal.2005).Thesestructuredinterviewmeasuresareusedinresearchstudiesorclinicalinterventionstohelpelicitandrateprogresswithgoals.

Setting SMART Goals:Whensettinggoals,itishelpfultoensurethatthoseselectedforinterventionareSpecific,Measurable,Achievable,Realistic,andTime-limited.Thefollowingareas/questionsshouldbeconsidered:

• Describe exactly what is to be achieved.

• What is needed to reach this goal?

• What might get in the way of reaching this goal?

• What resources are available to help meet this goal.

• What will help to overcome obstacles and achieve this goal.

• How do I know the goal has been achieved?

• What is the time limit?

2. Goal Indentification

Examples of Goals:Goalsmightfocusdirectlyontheimpactofcognitivedifficultiesinlifeorsomegoalsmayhaveabroader focus(e.g.socialising).Examplesofgoalsmightinclude:rememberingthenamesoffamiliarindividuals,rememberingimportantnumbers(PINcodes,phonenumbers),developingandusingastrategytohelprememberimportanteventsorkeeptrackofimportantpersonaleffects,rememberinghowtocarryoutmulti-componentdailytasks,learningtouseamemoryaidsuchasacalendarormemoryboard,orlearningandretainingpersonallyrelevantinformation.

Measuring Outcomes:Ifyouwishtomeasureoutcomes,itisbeneficialtogatherdataatthebeginningandattheendoftheintervention.TheBGSIallowsformeasurementofparticipant,carerandtherapistratingsofperformanceandsatisfactionforeachgoalidentified.AllratingsontheBGSIaretakenbeforetheinterventionbegins,andthenrepeatedatfollow-uptodeterminewhatchangeshaveoccurred.

Withsomegoals,itmightalsobeappropriatetomeasureactualgoalperformanceatbaselineandfollow-up.Anexampleofthismaybetorecordthenumberofcorrectresponsesonatestofface-namerecallconductedpriortoandaftertheintervention(seeClare,Wilson,Carter&Hodges,2003).Thisallowsformeasurementofactualgoalperformance,tosupplementself-ratings.


3. Guiding Principles

Throughouttherehabilitativeinterventionsessions,itisimportanttobeawareof–and toimplement,wherepossible,thefollowingguidingprinciples.

3.2 Dual Cognitive Support

Cognitiveimpairmentcanaffectpeoples’abilitytousemethodsthataidencodingandfacilitateretrieval.Itisimportanttoconsiderhowteachingstrategiesmightprovidesupportatbothencodingandretrievalbyensuringcompatibilityofcuesatencodingandretrieval(e.g.categorycues).Interventionsforpeoplewith cognitiveimpairment;comparedtohealthyolderadults, needtofocusonmoreguidanceandsupportwhenencodingmaterial,extralearningtrials,additionalprompts,andcuesforretrieval.

Multi-modal encodingcanbebeneficialinfacilitatinglaterrecallandisachievedbyinvolvingmultiplesensorymodalitiesduringlearning(e.g.providingsoundandsmellcuestoaccompanythedemonstrationofan actionsequence).

3.3 Errorless Learning

Errorlesslearningisaninstructionaltechniquethatallowsforthereductionoreliminationoferrorsduringlearning.Thisisparticularlyusefulinfacilitatinglearningorre-learningofinformationforpeoplewithcognitiveimpairment,asitminimisesthenumberoftimesthepersonisexposedtoanincorrectresponse(Clare,2008). ToachieveerrorlesslearningduringCRsessions,regularly remindtheindividualthatiftheyarenotsureofananswer,tosayeither“I’mnotsure”orjustdon’trespond.Whenthisoccurs,immediatelyprovidetheindividualwithacueorprompttoassisttheminrecallingthecorrectanswer.

3.1 Effortful Processing

Insomecases,whenapersonisaskedaquestion,the moreefforttheyarerequiredtomakeinordertoretrieve thecorrectanswer(i.e.thelesspromptsthatareprovided) thebetter.Forexample,researchshowsthathigheffortconditions(fewerprompts,moreeffortrequired)aremore effectivethanlow-effortconditions(giventheanswerimmediatelyorgivenalotofprompting)infacilitatingcuedrecallofnovelassociationsforpeoplewithcognitiveimpairment(Clare,2008).Itmayalsobebeneficialforface-namerecallornumberrecall.Toachieveeffortful processing,atencoding-assisttheindividualtoengageinelaborationoftheto-be-remembereditematencoding e.g.getthemtogenerateadditionalcuessuchas(i)thecategorythattheitemisinorapersonthatremindsthemofthatitem;(ii)otherrelatedmeaningsthatcanbeappliedtotheitem;(iii)orthinkoftheiteminanelaboratesetting(seealsomnemonics);self-generatedandmorepersonalcuesmaybemoreeffectivethancliniciangeneratedcues.Subsequentlyprovideminimumcuingtoaidrecall,suchasfirstletterorcategorycues.


4. Recall Strategies

4.2 Cueing

Providingrelevantcuesatrecallcanaidretrievalandcanbeusefulwhenteachinginformationparticularlyface-namerecallornumberrecall(Clare,2008).Twotypesofcueingarevanishingcues(orcueingwithdecreasingassistance)andforwardcues(orcueingwithincreasingassistance).Althoughonestudyreportednosignificantdifferencesbetweenthetwostrategies(Dunn&Clare,2007),twofurtherstudiesthatcomparedvanishingcuestoforwardcuesfoundforwardcuestobemoreeffective(Clare&Wilson,2004).

Example 4.2.1: VanishingCues(errorlessandeffortful):Eachfaceisfirstshownwiththecompletenameandoneachsubsequentpresentationaletteriswithdrawninorderfromrighttoleftuntilonlythefirstletterofthefirstnameispresented.Participantsareaskedtorecallthenamebycompletingthetarget,butnottoguess.Ifnoresponseisgiven,theprecedingstageisshownagain.Thisiscontinueduntilacorrectresponseisobtained.Onallsubsequenttrialswithinasession,aswellasbetweensessions,thenextstagehasonefewerletterthanthatatwhichtheparticipantssucceededinthecorrectcompletionontheprevioustrial(Dunn&Clare,2007).

Example 4.2.2: ForwardCues(errorlessandeffortful):Eachfaceisshowntogetherwiththefirstletterofit’sname.Participantsare askedtorecallorguessthenamebeginningwiththecue letter.Ifthecorrectresponseisnotgiven,lettersareaddedoneatatimeuntilacorrectresponseisobtained.Wherethefullnamehastobepresented,theparticipantisaskedtosaythecorrectnamealoud(Dunn&Clare,2007).

Example 4.2.3: Firstlettercueingcanalsobebeneficialfornamerecall.Gothroughthelettersofthealphabetonebyone;whenyoureachthefirstletteroftheperson’sname,itmaypromptrecall.

4.1 Mnemonics

Mnemonicsarelearningtechniquesthataidinformationretention.Usefulmnemonicsstrategiesincludelinkingvisualimagery,stories,poemsoracronymstotheinformationto-be-remembered.Preferablymnemonicsarecombinedwithothermethodssuchasspacedretrieval/repeatedpresentations.

Example 4.1.1: Amnemonicmethodmightinvolvediscussingaphotographandname,andgeneratingassociationsthatcouldbeusedtoassistrecall.Forexample:hisnameisEoin–imaginehimasanonion,Onion–Eoin;ORhisnameisBrian–hehasalargeheadsohemusthave abigbrain,Brain–Brian;OR“she looks like a girl I went to school with that has the same name”,etc.Bothpartiesshouldagreeonthemosteffectiveassociation.Itcanbedifficulttogenerateamnemonicbutworkatittogetherandtrytothinkofsomethinghumoroussothatitstandsoutmoretotheindividualwhenrecallingit.


4.3 Chunking

Chunkinginformationtogetherintocategoriesorsmallgroupscanbehelpfulwhenapersonneedstorememberlistsorgreateramountsofinformation.Organisinginformationintosmall,relevant,simplechunksorcategoriesmeansthatthereislessinformationtoremember.

Example 4.3.1: Practisemakingagrocerylistbychunkingitemsbasedontheirlocationsinthesupermarket,e.g.fruitandvegetables,dairy,meat,driedgoods,cleaningproducts,etc.Thentrycueinginformationbyassociatingitwithnumbers;5fruitandvegetablesitems,3meat,2dairy,etc.

Example 4.3.2.: Present12itemswithfourofeachitemwithinthesamecategory(e.g.dog,cat,horse,cow…shoe,hat,gloves,t-shirt,etc).Givetheinstructiontobreaktheseitemsdownintocategories.Oncetheyaresortedintocategoriestrytolinktheitemsinthecategorytogetherwithabizarrepictureorastory.Atrecall,encouragerecallofthecategoryfirst,thentheitemswithinthecategory.

4.4 Method of Loci

Theitemstoberememberedinthismnemonicsystemarementallyassociatedwithspecificphysicallocations.

Example 4.4.1: Visualiseyourhouse,visualiseyourselfgoingthrougheachroom,pickaspeciallocationineachroom.Whenyouaregivenalisttoremember,visualiseyourselfputtingoneitemineachspeciallocationinyourhouse.Practiseanumberoftimesforeachitem.Whentrying torecallitemsonthelist,imagineyourselfgoingfromroomtoroomcheckingthespeciallocations.

4.5 Spaced Retrieval

Spacedretrieval(SR)isalsocalled‘expandingrehearsal’,andhelpstoaidincreasedretentionofinformation.Thisstrategyisbeneficialforface-nameassociations,objectnaming,memoryforobjectlocationandprospectivememoryassignments(Clare,2008).InSR,testtrialsarespacedatgraduallyexpandingintervals.Forexample,showapictureofafacealongwithaname-thenshowthepictureandasktheindividualtorecallthenameafteranumberofsetintervals(e.g.5seconds,10s,30s,1minute,2m,5m).Ifacorrectresponseisgiven–theintervalisexpanded.Ifnot,thecorrectanswerisrehearsed,theindividualisaskedtorepeatthecorrectanswer–andtheintervalisshortenedtothepreviousintervalwheresuccessfulrecalloccurred(Buchanan,Christenson,Houlihan&Ostrom,2011).Thegoalismasteredwhentheinformationissuccessfullyrecalled atthefinaltime-point.Testingsessionsoccurwithin thecontextofasituationthatprovidessocialinteraction andreducesdemands,suchasacasualconversation.


5. Specific Interventions

• Nextpresentthepromptsinthereverseorderandgettheparticipanttorepeatthecorrectanswer (ifknown).

• Practisethemnemoniceachtimetheansweriscorrectlyidentified.

• Test phase:Afterpresentingallaboveprompts,asktheparticipanttorecalltheinformationatspacedintervals(SR).Forexample,testthemimmediately,thenafter30s,1m,2m,5m,10m.

• Iftheparticipantfailstorecalltheitem,reviewthecorrectnameandmnemonicandrepeatthatinterval.Iftheyareincorrectagain,halvetheinterval.Criterion for completion:accuraterecallafter10minutes.

• UseanERRORLESSLEARNINGtechnique.Asktheparticipantnottoguess,onlysaytheansweriftheyknowwhatitis.Iftheydonotknow,encouragethemtoeithersaynothingorsay“Idon’tknow”.Thisreducesthenumberoferrorstheparticipantmakes.

• Onlyaddonenewitempersessionandonlywhentheprioritemhasbeenlearned.

ThissectionprovidesconcreteexamplesofhowCRstrategiesmightbeputintopracticetotargetspecificgoals.TheexamplesaredesignedasaguidetoimplementingCRinterventionsandshouldbeusedinconjunctionwithCRresearchliterature.Interventionscanbeadaptedaccordinglydependingontherequirementsofindividualandonjudgementsofthehealthcareprofessional.Thepersonwiththememoryproblemisreferredtoasaparticipantastheyareparticipatingintheinterventionwiththehealthcareprofessional.

5.1 Face-Name Recall

Thefollowinginformationonface-namerecallsessionshasbeenadaptedfromClareandcolleaguesworkongoal-orientedcognitiverehabilitation(seeClare,Wilson,Breen&Hodges,1999;Clare&Wilson,2004;Dunn&Clare,2007).

• Presentaphotographoftheto-be-rememberedperson.

• Discussthephotographandname.Generatemnemonics(orassociations)thatcanbeusedtoassistrecall,andagreeonthemosteffectiveassociation.Forexample:ifthenametoberememberedisBrian–“Brianhasalargeforehead;hemusthaveabigbrain!BrainislikeBrian!”Basicallyyouneedtoworkwiththeparticipanttoattachavisualorastorytotheto-be-remembered-itemwhichwillhelpthemrecallit.Thiscanbechallengingbutitcanalsobefunandisaworthwhileexercise.

• Presenttheface-nameassociationandmnemonic.

• Forthetrainingphase,usingtheforwardcueingmethod,presentprompts,onelineatatime, withincreasingcues.Increasethecuesuntil theparticipantcorrectlyidentifiestheitem (seeFigure1below).


SESSION PLAN:Face-Name Recall

Item for training Shownphotographandtoldname(e.g.BRIAN).

Mnemonic chosen Discussedandagreedmnemonicforeachname

Learning Trials

Presentation 1

Presentation 2Presentation 3Presentation 4Presentation 5

CuewithincreasingassistanceHisnameisBrian:Shownandaskedtocomplete:

B____(notnamed)BR___(notnamed) BRI__(notnamed)BRIA_(nameidentified)

BRIA_BRI__BR___B____(Errorlesslearning:encouragesayingnothingor “Idon’tknow”ifunsure.Promptwithcorrectansin P2-5)Eachtimenamegivenorcorrectlyguessed–rehearsethemnemonic

Consolidation and Testing

Runonetrainingtrial(P1–5)thentestimmediately,after30s,1min,2min,5min,10min.Spacedretrieval.

Recording Onlyaddonenewnameinanygivensession.Testallnamesoncepersession(i.e.continuedbaselineforsuccessivenames)

Figure 1: Session plan for face-name recall goal. AdaptedfromClareetal.(1999);AppendixA:Example ofasessionplan(p.46).

5.2 Number Recall

Presenttheto-be-rememberednumbersinverbalandwrittenformats.Discussthenumber,whatitisfor, howoftenitisused,etc.

• Asabove,generatemnemonics(orassociations)thatcanbeusedtoassistrecall,andagreeonthemosteffectiveassociation.Forexample:Ifthenumbertoberemembered isadaughter’sphonenumber(086)8475350– “wemovedhousein‘84,mydaughterwasbornin‘75,andshegot350pointsinherleavingcert!”Trytolinkthemnemoniccuestotheparticipantorsituationpertainsto.Anotherexampleisacarregistration04D99617–(the04Dcanusuallyberecalledwithoutacue)“Myoldcarwasa’99, Igotmyfirstcarin’61,andIusedtodrivemy sevenbrothersandsistersaround”,etc.

• Next,forthetrainingphase,presenttheprompts,onelineatatime,withincreasingordecreasingcues(dependingontheindividual’spreferredstrategy).Increase/decreasethecuesuntiltheparticipantcorrectlyidentifiestheitem(seeFigure2,below).

• Nextpresentthepromptsinthereverseorderandgettheparticipanttorepeatthecorrectanswer (ifknown).

8______

8475___

84753__

847535_(numberidentified)

847535_

84753__

8475___

8______

Figure 2: Sample prompt for number recall task.

• Practisethemnemoniceachtimetheanswer iscorrectlyidentified.

• UsetheERRORLESSLEARNINGtechnique.


• After5-10presentationsofthetrainingmaterials,conductatestphaseusingspacedretrievale.g.ask theparticipanttorecalltheinformationimmediately, thenafter30s,1m,2m,5m,10m.

• Iftheparticipantfailstorecalltheitem,tellthemtheanswerandrepeatthatinterval.Iftheyareincorrectagain,halvetheinterval.Setaspecificcriterionforcompletion.

5.3 Story Recall

Whenyouwishtotargetmemoryfornewspaperarticlesorstories,trytoencouragetheindividualtouseeither(orboth)theWHquestionsorthePQRSTstrategy.Bothstrategiesshouldberehearsedwiththeindividualtotestforabilitytouse,preferenceandsuitability.

5.3.1: WH Questions: Whenreadingorlisteningtoastory,itmightbehelpfultofocusononlythekeypointsofthestory.Thisway,irrelevantinformationcanbeforgottenandthestorymayseemsimplifiedandeasiertorecall.Thinkofitasbreakingtheinformationdownintosections,andtry toimaginewhateachsectionlookslike:

• What • Where • Who • When • Why

5.3.2: You might also try or add in the PQRST strategy:

• P – Preview–readitoveragain,getanoverview ofwhatthestoryisabout

• Q – Question–who,what,when,where,why

• R – Read–readthroughitagain

• S – State–state/answeryourquestions (writeanswers)

• T – Test–testyourselftoseeifyouremember theanswerstoyourquestions

Encouragetheindividualtorehearsetheinformationanumberoftimestogettheinformationtostick.Usespacedretrieval(i.e.graduallyincreasethelengthoftimebeforeattemptingtorecalltheinformationagain).Practisebydiscussingthedetailsofthestorywithothersandthenchecktoseeifitiscorrect.Whenpresentingtheto-be-rememberedinformation,itispracticaltousestoriesofactualcurrentaffairsandnewsevents.

5.4 List/Object Recall

Tohelpwithrecalloflistsofthingsthatneedtobedone,orlistsofitemsneededforcookingorshopping,itmightbeusefultocombinethestrategiesofchunkingandthemethodofloci.Havetheparticipantimaginetheyarecarryingouttheactivityortaskandhavethemexplainthistoyouindetail.Conductanumberoftrainingtrials,andthenusespacedretrievaltotestforabilitytorecall.

5.5 Procedural Memory

Tooptimiseproceduralmemoryfunctioning,aimtotargettherestorationormaintenanceoftheabilitytocarryoutselectedtasksoractivitiesofdailyliving(Clare,2008).Tasksmightrangefromusingthephonetomakingbreakfast.Specificstrategiesandinterventionoptionsinclude;

5.5.1: Prompting and fading: Promptingmethodscanbeemployedtoassistwithtraining,andcanbefadedbacktoencourageeventualindependenceconductingthetask.Atask-analysisisrequiredtoidentifythekeystepsincarryingoutthetask.Promptsmaybeverbalprompts(“nowpickupthephone”),modelprompts(modellingtherequiredactionfortheindividualtoimitate),gesturalprompts(pointingorgesturing)orphysicalprompts(guidingtheparticipantshandtothephone).Alwaysbeginwiththeminimumrequiredprompt.Graduallyfadebackasperformanceimprovesuntiltheparticipantindependentlycarriesoutthetask.


5.5.2: Action-based encoding: Insteadofonlyprovidingaverbalinstruction,whereappropriate,theparticipantcouldalsophysicallyengageincompletingthetaskalongwiththeverbalinstructionatthetimeofencoding.Provideappropriatecuesatthetimeofretrieval(e.g.“nowit’stimetowashyourhands”andpointtothetap)astheindividualmaybelesslikelytoindependentlyinitiatethecorrectresponseatthecorrecttime.

5.5.3: Chaining: Chainingisusefulforrelearningtaskswithvarioussteps,suchasmakingbreakfast,brushingteeth,fishing,etc.Conductataskanalysistoidentifythekeystagesincompletingataskandthespecificactionsrequiredbytheparticipantateachstage.Conductanassessmentoftheparticipant’sperformanceofeachstagetodeterminetheappropriatelevelofpromptingrequiredforeachstepinthetask.Fadebackpromptsuntileachstepcanbecarriedoutindependently.Teachasachainofbehavioursothateachstepbecomesapromptforthenext.

Backward Chaining:Theparticipantisfullyprompted(visual,verbal,andmodelprompts)througheachstepofthetaskfirst.Inthenexttrial,allstepsarepromptedexceptpromptsarefadedbackforthelaststepuntilitbecomesindependent.Workbackwardssuccessivelythroughstepsuntiltheparticipantcancompletetheentiretaskindependently.

Forward Chaining: Theparticipantisfullypromptedthrougheachstepofthetaskfirst.Inthenexttrial,allstepsarepromptedexceptpromptsarefadedbackforthefirststepuntilitbecomesindependent.Workforwardsuccessivelythroughstepsuntiltheparticipantcancompletetheentiretaskindependently.

5.6 Fluency Training

–DirectInstructionandPrecisionTeaching

Fluencytrainingisthoughttoproducebetterlearningoutcomesincludinglong-termmaintenance,theability todisplayskillsinadistractingenvironment,andan increasedlikelihoodofcomponentskillsbeingappropriatelyappliedinpractice(Kubina&Wolf,2005).Belowisasuggestedstrategyfortrainingtofluency.Othersmay befoundinPrecision Teaching(Lindsley,1991)andDirect Instructionliterature(http://www.education.ie/en/Education-Staff/Information/NEPS-Literacy-Resource/NEPS-Resource-Precision-Teaching-Approach.pdf).

Identifythematerialthatyouwishtotraintofluency.Here,weusetheexampleofface-nameornumberrecall.

5.6.1: Fluency Training – Names:

• Showthepicturesoneatatime.“Thisis__(name)”andprintedtext.

• Foreachpicture,instructtheparticipantto“Tellmesomethingabouthim/her”?Anythingtheyknowisfine,even1or2piecesofrelevantinformation.Iftheyknowverylittle,suggestsomeadditionalinformationthatmaydifferentiatetheto-be-rememberedparticipant.

• Aftereachhasbeenindividuallynamedanddiscussed,putallpicturesoutonthetableatthesametimeandsay“pointto__(name)”.Continuewithallpicturesx2.

• Pickupphotos,shuffle,putthemdownoneatatimeandasktheindividualtonameeachparticipant.

• Repeatthisentireprocess2to5timesoruntildeemedappropriatetomovetothetestphase.


5.6.2: Fluency Training – Numbers:

• Identifyimportantnumbers.

• Saythenumbersoutloud.

• Asktheparticipant“Whatisthisnumberfor?”

• Theparticipantshouldwriteouteachnumbertwice.

• Placewrittencopiesofeachnumberonthetableoneatatimeandasktheparticipanttoidentify thenumberandsayitoutloud.

• Repeat2to5times,asabove.

• Afterthefluencytrainingsessionsarecomplete,youneedtorunatest trial.Thisconsistsofsettingatimerforoneminuteandrecordinghowmanynames/numberstheparticipantcancorrectlyrecallperminute.Alsorecorderrors.Gettheparticipanttorecordthese–placethedatainatablesotheparticipantcantracktheirownperformance.

• Aimtocompleteuptoeightsessions.

Sessions S1 S2 S3 S4 S5 S6 S7 S8

Correct/minute

8 10 23 30 24 34 26 32

No.oferrors

1 2 2 0 0 0 0 0

TABLE 1: Sample table for recording performance during fluency training

5.7 Semantic Impairments

Rehabilitationinterventionsmaybeconsideredforindividualswithsemanticimpairments,suchastemporalvariantfronto-temporaldementia(Clare,2008).Although thisareaofworkisstillinitsinfancy,researchshowsthatthefollowingtechniquescanbebeneficial-inalleviatingsemanticimpairments.

• Repeatedrehearsalofnamesofconceptsoritemspairedwithpicturesorexemplarshasbeenshowntoimproveaparticipant’sabilitytoproducepreviouslyhardtoretrievewords.Constantpracticewasneededthough(Grahametal.2001).

• Recentresearchhasshownthatsimple,repetitivepracticeofword-picturepairingina3-weekword-trainingprogrammesignificantlyimprovedtheabilitytonametraineditemforfourpeoplewithmildtosevereimpairmentsinsemanticknowledge(Savage,Ballard,Piguet&Hodges,2013).SeeSavage etal.(2013)formoreinformationandadiscussion aboutresearchonstrategiesforre-buildingvocabularyinindividualswithsemanticimpairments, withpromisingresults.

• Learningismoreeffectivewhen:1)theindividualretainssomesemanticknowledgeoftheitem,objectorconcepttobelearned;and2)learningissupportedbytheavailabilityoftemporalandspatialcontextualinformationrelevanttotheparticipant’sdailylife(thiswaylearningextendsbeyondverballabelstoassociatedrelevantknowledge).Effectivelearningmightrequirethematerialtobelinkedwithpersonalexperience(Snowden&Neary,2002).

• Researchsuggeststhatrehabilitationininthosewithsemanticimpairmentsshouldfocusonmaintenanceofcurrentvocabularyratherthanrelearningforgottenvocabulary;usingrepetitioncombinedwithamulti-modalapproachinvolvingmanipulation,namingandrichdescriptionofobjects(Reilly,Martin&Grossman,2005).


5.7.1: Forindividualswithmore mild impairments including word finding difficulties duringconversation,orissueswithverbalfluency,itcanbebeneficialtopractise:

• Word-pairs:provideawordandasktheindividualtopairitwithanotherappropriateword.

• Wordassociations:provideonewordandasktheindividualtoidentifyarelatedwordorawordwiththesamemeaning.

• Commonlyusedfluencytests(e.g.F,A,Stest)e.g.gothroughlistsofwordsbeginningwithF,thenpresentabriefoneminutetestsession.PresentrepeatedexposurestolistsandoneminutetestsinsuccessivesessionsAllowindividualstokeeptrackoftheirownscorestotrackanyimprovementsorprogress.

• Userepeatedpresentationsandpracticeacrosssessionsusingmultipleexamples.

Word Pairs Word Associations Letter F Fluency Test

Share----KnowledgeBe----CreativeRemain----HopefulMeet----NeedsPromote---HealthSupport----FamilyRemember----MeBuild----StrengthSimilar----ToPrepare----ForTake----ResponsibilityShine----BrightlyFill----UpLast----Night

Father----DadSon----ChildMother----MumCar---AutomobileBicycle----BikeTrain----Bus/TransportCup----MugJug----PitcherMedication----TabletsCow----FarmAnimalPen----PencilPaper----PageLamp----LightCouch----Chair

FastFarFallFlyFilmFitFullFriedFlingFlickFrontFakeFatherFeather

TABLE 2: Examples of word pairs, word associations and responses for the letter F fluency test

Forthistypeofintervention,asktheindividualtoidentifycommonwords,word-typesorcategoriesthattheytypicallyfinddifficult(theparticipant’sfamilymaybeabletohelpwiththisalso).Basedontheinformationprovided,selectrelevantwordsforwordpairingandassociations.Practisingparticularwordassociationsandwordpairsmaynotnecessarilygeneralisetofluencyofallspeechineverydaylivingbutcanprovideconfidenceandpracticeinspecificareasofdifficulty.


6.1 Memory Aids

Providingexternalsupportintheformofcompensatorymemoryaidscanhelptoreducedemandsonimpairedaspectsofmemory,providecognitivesupport,reduceanxietyandevenpromotesocialengagement.

Selectionofaidsrequirescarefulconsideration–where useoftheaidisalreadywithinthebehaviouralrepertoire, focusshouldbeonmoreregularorefficientuse;whileifnewlearningisrequired,useaninterventiontoaddressthisbeforeeverydayimplementationisexpected.Forgeneralisedreminders,theassociationwiththedesiredresponseneedstobecarefullytaught.Aidsneedtobeacceptabletotheindividual,accessibleandeasytouse.

Specificstrategiestoconsiderfortrainingassociationwithmemoryaidsinclude:

• Action-basedlearning• Promptingandfading• Modelling• Errorlesslearning• Chaining

6.2 Environmental Adaptation

Adapttheenvironmenttobemoreorganised–aplaceforeverythingandeverythinginitsplace.Encouragethedevelopmentofhabitsandroutinessothatitemsareplacedonlyinspecificlocationsandalwaysplacedbackthereafteruse.Forexample:Akeyholderbythedoorforallkeys;a‘specialplace’ineachroomforglasses,wallet,phone;an‘in’trayforbillsandletters;letterstopostbythedoor,etc.Encouragestrategicplacementofobjectswhenout–e.g.bag/umbrellainfrontofyouoronyourlap.Thismayrequireanobject-locationpairinginterventionwheretheobjectisplacedinthecorrectlocationrepeatedly;useactionbasedencoding,spacedretrieval,mnemonicsanderrorlesslearning.Reinforcecorrectplacement.

6.3 Relaxation

Examplesincludebreathingtechniques,progressiveorpassivemusclerelaxation,yoga,relaxationclasses,exerciseinterventions,mindfulness,etc.Discusswiththeindividualandfindoutwhatrelaxationmethodsuitsthembest.Providetheparticipantwithappropriatereadingmaterials,informationaboutclassesandtechniquesthataresuitedtotheirneeds.Ifpossible,practiserelaxationstrategieswiththeindividualduringtheCRsessions.

6. Additional Support


7. Examples of CR in Practice

Case 1:

Number & Face-Name Recall

Joewas75yearsoldwithearly-stageAlzheimer’sdisease.Hehaddifficultywithremembering important numbers like PIN codes,andthe names of peoplefromhisclub.

ThenumbersincludedintheinterventionwereJoe’sPINcode,housealarmcode,carnumber-plate,andhismobilephonenumber.Thenumbersweretargetedonebyone–thatis,thetherapistonlyworkedononenumberatatime.WhenitwasdeemedthatJoehadlearnedthatnumber,thetherapistmovedontothenextnumber.First,thenumberwaschunkedtogether(i.e.conceptualising3-5-6as356).NextthetherapistworkedtogetherwithJoeonselectingaverbalmnemonicforeachnumber(seesection5.2,page9).Trainingsessionsconsistedof5-10presentationsoftheto-be-learnednumberusingforwardcues(seefigure3),followedbyrehearsalofthenumberusingspacedretrieval(seesection3.3andsection5.2)atthetimeintervalsof0s,30s,1m,2m,5m,10m.Themnemonicwaspractisedeachtimethenumberwascorrectlyidentified.Ifanincorrectornoresponsewasgivenatacertaininterval,thetherapisttoldJoethenumberandtheintervalwasrepeated.Ifthisoccurredagain,theintervalwashalved.ThelearningsessionwascompletewhenJoecorrectlyrecalledthetargetnumberafter10minutes.Alllearnednumberswererehearsedonceinaprobesessionattheendofeachinterventionsessiontoensurethatpreviouslylearnednumberswerenotforgottenwhenthenewnumberwasintroduced.Notethaterrorlesslearningwasadoptedthroughout–Joewasremindednottoguess,onlysaytheanswerifheknewit.Ifhedidnotknow,hewasencouragedtoeithersaynothingorsay“Idon’tknow”.

ThisstrategyworkedwellforJoe,soitwasadoptedfortheface-namerecalltaskalso.Tohelprememberthenamesofhisclubmembers,Joeandthetherapistselectedthefivenameshewasmostlikelytoforget(Joeattendedtheclubandbroughtanotebooktorecordthenameshewantedtoworkon).Joehadapictureoftheclubmembersfromarecenteventwhichwasusedfortheintervention.Recallofthefivenameswastargetedusingtheinterventionoutlinedinsection5.1.Asabove,onlyonenamewastargetedatanygiventime.First,Joespokeabouttheperson,whathe/shelookedlike,theirpersonality,etc.ThenJoeidentifiedthemnemonicfortheperson.Inlearningsessions,thenamewaslearnedusingthepictureandforwardcues(asinsection5.1).Thenamewasrehearsedusingspacedretrievalatthetimeintervalsof0s,30s,1m,2m,5m,10m.Themnemonicwaspractisedeachtimethenamewascorrectlyidentified.Ifanincorrectornoresponsewasgivenatacertaininterval,thetherapisttoldJoetheperson’snameandtheintervalwasrepeated.Ifthisoccurredagain,theintervalwashalved.ThelearningsessionwascompletewhenJoecorrectlyrecalledthetargetnameafter10minutes.Onlyonenewnamewastrainedpersessionbutaprobeofallnameswasalsoconductedattheendofeachsession(asabove).


Case 2:

Face-Name Recall & Conversational Fluency

Marywas62yearsoldwithyoungeronsetdementia,andwasexperiencingmildimpairmentsasaresultofherdementia.Marywantedtoimprovehermemory for the names of characters in the TV soapsshewatchedwithherhusband;andherabilitytoremember words during conversation.

Theface-namerecallinterventiontargetedrecallof10face-nameassociationsofTVsoapstars;andemployed directinstructionandprecisionteaching(seesection5.6)methodologies.Maryandherhusbandassisted thetherapistinidentifyingthe10namestheywantedtoworkon.Duringinterventionsessions,photographs ofthesoapstarswereplacedonthetableonebyone,andthenameswereidentified.ThetherapistagainplacedthepicturesonthetableonebyoneandaskedMarytorelay2-3piecesofinformationabouteachperson“tellmeabouthim?”Next,thetherapistplacedallpicturesonthetableatthesametimeandsaid“pointto__”andthenameofeachperson.Thiswasrepeated2-3times.AllphotographswerethenpickedupandshuffledandplacedonthetableonebyoneforMarytoname.IftheMarydidnotknowthename,thetherapistwouldnamethepersoninthepictureandchataboutthepersonusingtheinformationpreviouslyidentified.Whenallthepictureswerecorrectlynamed,aoneminutefluencytest-sessionwasconducted.Maryrecordedherownperformanceateachinterventionsession,andnotedimprovementsweektoweek(e.g.seetable1).

Maryalsohadtroublewithwordfindingduringconversations.Thewordwouldusuallycomebacktohereventuallybutitbotheredherthatsheoftenforgotwordsandshenotedthatherconfidencewasaffectedwhenspeakingtopeople.ThetherapistaskedMarytowritedownwordsshehaddifficultyrecallingonaweek-to-weekbasis.Duringtheinterventionsessions,Maryandthetherapistcompiledalistofthesewords(andsimilarwords),andcreatedwordassociationlists–wherealternativewordswiththesameorsimilarmeaningtothetargetwordweregenerated.ThetherapisttoldMarythatifshecouldnotthinkof aspecificwordduringaconversation,thatperhapsshecouldtrytothinkofasuitablealternative(asinthewordassociationlists).Marypractisedrehearsingthelistsbetweensessions.Duringsessions,Maryandthetherapistreadovertheliststogetherandcompletedoneminutetestsessions.Inadditiontothewordassociationlists,MaryandthetherapistwrotelistsofwordsbeginningwiththelettersF,A,andS,andwrotelistsofanimals,fruit,vegetables,etc.Maryalsoworkedonrehearsingtheselistsbetweensessions.Marytrackedherownprogressfromweektoweekontheoneminutetests,andnotedimprovements.Althoughthepossibilityforgeneralisationtoeverydayconversationwasquestionable,Maryreportedfeelingmoreconfidentduringconversationsandbeingmoredeterminedtotryhardertoretrievethecorrectwordorasuitablealternative.Herfamilyalsoreportedanimprovement.


Case 3:

Playing Bridge

Johnwas68andhadadiagnosisofMildCognitiveImpairment(MCI).HeengagedinarangeofweeklyactivitiesincludingBridge,Golf,andattendingGAAgames.Hereportedmostdifficultywithplaying Bridge duethenumberofcomplexrulestoberememberedwhileplaying.

TotargetJohn’sabilitytoplayBridge,theinterventionworkedontheuseofmemoryaids,andrepeatedpracticeofimportantconventions.ThetherapisthadnopriorexperienceofplayingbridgeandsoaskedJohnifhecouldhelphertolearn.Johnwasaskedtowritedowntherulesofbridge,alongwiththemostimportantconventionsthatanoviceshouldknow(Johnworkedoncompilingthesewithhiswifebetweensessions).Thetherapistinitiallytargetedtherules;andthenworkedonapproximatelyoneconventionpersession.Priortoeachsession–thetherapistflaggedwithJohnwhatconventionwouldbeworkedoninthenextsessionandhewasrequiredtobringinhisnotesaboutthatconventionforthesession.Duringinterventionsessions,Johnwasaskedtonametheconvention,talkaboutit,andwritedownthemostimportantpoints.Johnwasthenaskedtohelpthetherapisttolearntheconvention(usingplayingcardsandnotes).Repeatedpracticewasconductedthroughouteachsessiontoensureclarityonhowtouseeachconvention,howitfitintoa‘standardbiddingsystem’,etc.Attheendofeachsession,thetherapistworkedwithJohnondraftingkeysummarypoints,andtheytestedeachother’sknowledgebyaskingquestionsbasedonthesummaryinformation.Asabove,anerrorlesslearningstrategywasemployed,and onlyonenewpieceofinformationwasintroducedatatime.Thetherapistconcludedsubsequentsessionsbyconductingaprobeof1-2questionsonconventionstargetedinpriorsessions,toensureretentionofimportantinformation.Importantly,Johnwasencouragedtousehisnotesduringgameswhenhehad difficultyrememberingdetailsofacertainconventions.Thisway,Johnbuiltupanotebookofimportantrulesandconventions,andcoulduseitfluentlywhenrequired.ItshouldbenotedthatBridgeisverycomplex.Johnwasencouragedtofocusononlythemostimportantrulesandconventions(thatwere deemedmanageableforhisabilities).Althoughthiswouldallowhimtocontinuetoplay,itwasacknowledgedthathemaybelimitedinmorecomplexplayingcircles.


Case 2:

Using the Phone & Repetitive Questions

JanewasdiagnosedwithearlystageAlzheimer’sdiseaseat75.Janehadabusysociallife,asshehadalargefamilyandanumberofgrandchildren.Shereporteddifficulty with using her phone, and her family noted that she repeatedly asked about the time, dates and appointments.

Janewashavingdifficultyrecallingthesequenceofactionsrequiredtomakeaphonecallusinghermobilephone.Thetargetactivitywasbrokendownintosmallsteps(1.Unlockthephone;2.Enterpin-code;3.Select‘contacts’;4.Scrolltothenumberyouwishtocall;5.Pressthe‘CallButton’;6.Presstheredbuttontohangup).Thesequenceofactionswastaughtusingbackwardchaining,promptingandfading(seesection5.5).ThetherapistdeliveredverbalandgesturalpromptstoJaneforsteps1-6inthechain.Promptsweresubsequentlyfadedbackforstep6.Whenstep6wascompletedindependently,promptswerefadedbackforstep5,andsoonuntilallstepsinthechaincouldbecompletedindependently.Actionbasedencodingwasimplementedthroughout,i.e.Janecompletedtheactivityherselfateachstep.Asmasteryincreasedduringinterventionsessions,thetherapistaskedJane’sfamilytoprompthertomakephonecallsthroughouttheday,andalsotoreinforceherwithextrapraiseandconversationifshemadecallsunprompted.

Awhiteboardwithinformationabouttheday,date,andappointmentswasplacedonawallinJane’skitchen.Janealwaysworeawatchbutdidnotuseittotellthetime.Atrandomintervalsduringinitialinterventionsessions,thetherapistaskedJaneeitherthetimeoraboutanupcomingappointmentandthenimmediatelypromptedhertocheckthewhiteboardorherwatch.Janegladlyprovidedtheinformationtothetherapist,whoreinforcedherbysaying“it’sgreatthatyoucanusethatwhiteboard”or“ifyouaren’tsurewhattimeitisyoucanalwayslookatyourwatch”,“that’salovelywatch”,etc.Promptsweregraduallyfadedbackduringsubsequentsessionsusingaprogressivetimedelayof1s,2s,3s,5s,8s,10s.Inresponsetospontaneousquestions,Janewasgivenastandardresponse–“checkyourwatch/thewhiteboard”.Jane’sfamilywereinstructedtodirectJanetoherwatch/whiteboardatrandomintervalsthroughoutthedaybyaskingherabouttimeorappointments,andalsotogivethestandardresponseifsheaskedthemquestions.Jane’shusbandalsoremindedhereachnightbeforebedtochangetheinformationontheboardsothatshewasresponsibleformanagingtheboard,andtoensuretherelevantinformationwasavailableeachday.

* Note that for all CR interventions, substantial time and effort practising the intervention outside of sessions is required by each participant, and their family/ carer. CR was most successful when the participant adopted the strategies, practised frequently, and attempted to apply learned strategies to other areas of difficulty.


SincerethankstoProfLindaClare,DrRobertCoen,DrAndreaHiggins,ProfBrianLawlor,andSheenaCadoofortheirworkonproof-readingthemanualandsendingsuggestions;andtotheindividualsandtheirfamilies whoparticipatedinCognitiveRehabilitationresearchstudieswithDrKellyandDrO’Sullivan.

ThankyoutoProfSabinaBrennan,ProfIanRobertsonandalloftheNEILTeamintheInstituteofNeuroscience,TrinityCollegeDublin;andtoMsGrainneMcGettrickandallofthestaffatTheAlzheimerSocietyofIrelandforthesupportprovidedtoDrKellyinconductingtheresearchandcompletingthemanual.ThanksalsotoMrJohnDonoghueandhisfamilyfortheirkinddonations whichhelpedtosupportthedisseminationofthiswork.

ThefirstauthorwasemployedbyTheAlzheimerSociety ofIrelandandtheNEILProgrammeintheTrinityCollege InstituteofNeuroscienceduringthewritingofthismanual; apositionfundedbytheDepartmentofEnvironment,CommunityandLocalGovernment.ThepublicationofthemanualwaspossiblethroughfundingfromtheIrelandFunds.

Allrelevantthirdpartieshavebeeninformedof,andhave giventheirconsenttothepublicationofthemanual.

Acknowledgements Funding/Permissions


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References

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