Cog­ni­tive re­hab for de­men­tia suf­fer­ers

De­men­tia may never im­prove, but many pa­tients still can learn

Bangkok Post - - LIFE - PAULA SPAN

He was a re­tired fac­tory worker, liv­ing with his wife out­side a small town in Wales, in the United King­dom. Once out­go­ing and so­cia­ble, en­gaged in lo­cal ac­tiv­i­ties in­clud­ing a com­mu­nity choir, he’d been jolted by a di­ag­no­sis of early de­men­tia. A few months later, at 70, he wouldn’t leave the house alone, fear­ful that if he needed help, he couldn’t man­age to use a cell­phone to call his wife. He avoided house­hold chores he’d pre­vi­ously un­der­taken, such as do­ing laun­dry. When his frus­trated wife tried to show him how to use the washer, he couldn’t re­mem­ber her in­struc­tions. “He’d lost a lot of con­fi­dence,” said Linda Clare, a clin­i­cal psy­chol­o­gist at the Univer­sity of Ex­eter. “He was ac­tu­ally ca­pa­ble, but he was fright­ened of mak­ing a mis­take, get­ting it wrong.” Clare di­rected a re­cent trial of cog­ni­tive re­ha­bil­i­ta­tion in Eng­land and Wales in which the pa­tient was en­rolled. Cog­ni­tive re­ha­bil­i­ta­tion, which Clare has been re­search­ing for 20 years, evolved from meth­ods used to help peo­ple with brain in­juries. The prac­tice brings oc­cu­pa­tional and other ther­a­pists into the homes of de­men­tia pa­tients to learn which ev­ery­day ac­tiv­i­ties they’re strug­gling with and which abil­i­ties they want to pre­serve or im­prove upon. Or­ga­niz­ing a visit with a friend, per­haps. Keep­ing track of the day’s ap­point­ments and plans. Heat­ing a pre­pared lunch without burn­ing it. In weekly ses­sions over sev­eral months, the ther­a­pists de­vise in­di­vid­ual strate­gies that can help, at least in the early and mod­er­ate stages of the dis­ease. The ther­a­pists show pa­tients how to com­pen­sate for mem­ory prob­lems and prac­tice new tech­niques. Cog­ni­tive re­hab has its lim­i­ta­tions. “We never sug­gest this can re­verse the ef­fects of de­men­tia,” Clare said. It will not raise par­tic­i­pants’ scores on tests of men­tal abil­ity. But she and other Euro­pean re­searchers have demon­strated that peo­ple with de­men­tia can sig­nif­i­cantly im­prove their abil­ity to do the tasks they’ve opted to tackle, their cho­sen pri­or­i­ties. Those im­prove­ments per­sist over months, per­haps up to a year, even as par­tic­i­pants’ cog­ni­tion de­clines in other ways. “They want to be en­abled to man­age their lives,” said Clare. “It gives hope that they can han­dle ev­ery­day chal­lenges.” This ap­proach may rep­re­sent the fu­ture for the grow­ing num­ber of older adults around the world with de­men­tia. Tri­als of drugs to pre­vent or treat de­men­tia have failed over and over. Even if some fu­ture treat­ment demon­strated ef­fec­tive­ness, mil­lions of peo­ple and their stressed fam­ily care­givers need help now. “We can’t wait an­other 20 years for some magic pill,” said Laura Gitlin, dean of the Col­lege of Nurs­ing and Health Pro­fes­sions at Drexel Univer­sity. She has de­vel­oped some­thing called the Tai­lored Ac­tiv­ity Pro­gram (TAP), some­what sim­i­lar to cog­ni­tive re­hab, which also brings oc­cu­pa­tional ther­a­pists into peo­ple’s homes. “We’re try­ing to lay the sci­en­tific ba­sis for non­phar­ma­co­log­i­cal ap­proaches,” Gitlin said. “These stud­ies sig­nal that they can have pow­er­ful ef­fects on peo­ples’ lives.” In the United King­dom, for in­stance, a gov­ern­ment-sup­ported trial in­volv­ing 475 peo­ple with early-stage de­men­tia found that after cog­ni­tive re­hab, most par­tic­i­pants at­tained their goals, while those in a con­trol group did not, and they main­tained im­prove­ment at three months and nine months. (The study has not yet been pub­lished; Clare pre­sented the re­sults at a con­fer­ence last year.) A smaller trial of cog­ni­tive re­hab by Bel­gian re­searchers, re­cently pub­lished in the Jour­nal Of Ge­ri­atric Psy­chi­a­try And Neu­rol­ogy, found that pa­tients with early Alzheimer’s dis­ease re­mained bet­ter able to do their cho­sen ac­tiv­i­ties after a year. “More and more, peo­ple will un­der­stand how many pre­served abil­i­ties there are in de­men­tia, and that will help change minds,” said Eric Salmon, direc­tor of the mem­ory clinic at the Univer­sity of Liege in Bel­gium and the se­nior au­thor of that study. In the United States, Gitlin’s TAP pro­gram in­cludes more pa­tients with se­ri­ous cog­ni­tive loss than cog­ni­tive re­hab does. And it takes a some­what dif­fer­ent tack: TAP aims to re­duce the trou­bling be­hav­iours that can ac­com­pany de­men­tia: re­peated ques­tions, wan­der­ing, re­ject­ing as­sis­tance, ver­bal or phys­i­cal ag­gres­sion. A pi­lot study found that with TAP, the fre­quency of such be­hav­iours de­creased com­pared to a con­trol group, al­low­ing fam­ily mem­bers to spend fewer daily hours car­ing for pa­tients. Since then, Gitlin and her team have used TAP (and a re­lated re­ha­bil­i­ta­tive pro­gram called Cope) in a va­ri­ety of set­tings: hos­pi­tals, as­sisted liv­ing and nurs­ing homes, with vet­er­ans, in com­mu­nity and vol­un­teer groups. “Let’s think of these as treat­ments, with the same level of ev­i­dence as if you went to a doc­tor and got a pill, but with no ad­verse ef­fects,” Gitlin said. “This is what’s ef­fec­tive.” Many re­searchers are un­aware of cog­ni­tive re­hab and its vari­ants. Pro­grams use dif­fer­ent num­bers of ses­sions, some­times with fol­low-up “booster” vis­its, some­times not. The stud­ies haven’t fol­lowed pa­tients be­yond a year to see how long their im­prove­ments last, or whether more ses­sions might bol­ster those re­sults. The cost for the TAP in­ter­ven­tion, Gitlin’s anal­y­sis shows, was a com­par­a­tively mod­est US$942 (30,000 baht) per per­son in 2009. If her pro­gram or cog­ni­tive re­hab helps keep peo­ple at home, or pre­vents hos­pi­tal­i­sa­tion or emer­gency-room vis­its, it might ac­tu­ally save money. One could ar­gue that even when it works, cog­ni­tive re­hab has only a mod­est im­pact. Com­pared to the dev­as­ta­tion de­men­tia even­tu­ally in­flicts — the years­long toll on fam­ily care­givers, the health care costs — how much of a tri­umph is it to be able to use a TV re­mote for a few ad­di­tional months or a year? To make a cup of tea or walk the dog? But there’s so lit­tle good news for peo­ple with de­men­tia. They and their fam­i­lies might wel­come re­ports of a re­ha­bil­i­ta­tive ap­proach that could re­duce frus­tra­tions and make life eas­ier, even for a lim­ited time. “It’s so sen­si­ble,” said Steven Zarit, a long­time re­searcher of de­men­tia and care­giv­ing at Penn­syl­va­nia State Univer­sity. “In­stead of try­ing to de­lay changes in cog­ni­tion, it tries to de­lay changes in func­tion. Peo­ple can do more for them­selves, and have a bet­ter life be­cause of it.”

It gives hope that they can han­dle ev­ery­day chal­lenges

Newspapers in English

Newspapers from Thailand

© PressReader. All rights reserved.