STRATEGIES AND TECHNIQUES FOR COGNITIVE …

1 STRATEGIES AND TECHNIQUES FOR COGNITIVE REHABILITATIONM anual for healthcare professionalsworking with individuals with COGNITIVE impairmentDr Michelle E. Kelly ( , BCBA-D)Dr Maria O Sullivan ( , Clin Psych)JULY 20151. Overview 32. Goal Identification 43. Guiding Principles Effortful Processing Dual COGNITIVE Support Errorless Learning 54. R ecall STRATEGIES Mnemonics Cueing Chunking Method of Loci Spaced Retrieval 75. Specific Interventions Face-name Recall Number Recall Story Recall List / Object Recall Procedural Memory Fluency Training Semantic Impairments 126. Additional Support Memory Aids Environmental Adaptation Relaxation 147. Ex amples of CR in Practice Case 1 Number & Face-Name Recall Case 2 Face-Name Recall & Conversational Fluency Case 3 Playing Bridge Case 4 Using the Phone & Repetitive Questions 18 Acknowledgements 19 References 20 STRATEGIES AND TECHNIQUES FOR COGNITIVE REHABILITATION Manual for Healthcare Professionals Working with Individuals with COGNITIVE ImpairmentSTRATEGIES AND TECHNIQUES FOR COGNITIVE REHABILITATION 2 Disclaimer COGNITIVE REHABILITIATION MANUALNo adviceThis COGNITIVE rehabilitation manual ( CR MANUAL ) contains general information regarding COGNITIVE rehabilitation STRATEGIES .

2 The manual has been by created by Trinity College Dublin and The Alzheimer Society of Ireland ( AUTHORS ) during the course of their academic research collaboration. The information is not to be considered as comprehensive medical advice, and should not be treated as such and should be used in conjunction with additional supporting therapies where of the CR MANUAL is prohibited under the following conditions: licensing, leasing, or selling the CR MANUAL, or distributing the CR MANUAL for any commercial of Warranties & LiabilityThe CR Manaul comes as is , with no warranties. This means no express, implied or statutory warranty, including without limitation, warranties of mechantability or fitness for a particular purpose or any warranty of title or non-infringment. The authors make no representations or warranties in relation to the medical information contained within the CR Manual to the maximum extent permitted by applicable law, the authors expressly disclaim all, and shall not be deemed to have given any warranties, express or implied (by law or otherwise), in relation to the CR Manual and the use of the CR assistanceThe CR MANUAL should not be used as an alternative to medical advice from any doctor or other professional healthcare provider.

3 Any specific questions about any medical matter should be in consultation with a doctor or other professional healthcare AND TECHNIQUES FOR COGNITIVE REHABILITATION 3 The aim of this manual is to present healthcare professionals with STRATEGIES and TECHNIQUES that can be used to assist people with memory problems in optimising management of their daily lives and activities. These STRATEGIES have been incorporated into goal-oriented COGNITIVE rehabilitation interventions that aim to (i) draw on retained strengths to support adaptive behaviour; and (ii) achieve optimum levels of wellbeing by targeting performance on personally relevant goals (Clare, 2008). The manual is not a comprehensive account of COGNITIVE rehabilitation (CR) however, and should be used in conjunction with supporting literature ( Clare, 2008; Clare & Wilson, 2004; Dunn & Clare, 2007; Clare et al., 2010). There are a number of different rehabilitative STRATEGIES outlined in this manual aimed at assisting with difficulties in memory and everyday functioning.

4 Generally speaking, there is a lot of individual variability in how people respond to different STRATEGIES . For this reason, it is preferable to try several STRATEGIES in an attempt to determine what works best for each individual. As the healthcare professional, your role is to help the individual understand how to use these STRATEGIES , but the individual is responsible for practice and implementation between sessions. Explain that there is a requirement of commitment and effort on their part. Typically, you would identify target areas or goals to work on, practise a number of different STRATEGIES , and then decide which STRATEGIES the person prefers and can use most efficiently. Preferred STRATEGIES can be selected for additional practice until the individual feels confident using should be conducted either in the person s home, or in a comfortable setting suited to practising the identified goals.

5 Family members/carers should be debriefed on each session and provided with explanations of STRATEGIES used so that these may be practised outside of intervention sessions. 1. Overview Rehabilitative STRATEGIES and Interventions:GUIDING PRINCIPLES RECALL STRATEGIESSPECIFIC INTERVENTIONSE ffortful Processing Dual COGNITIVE SupportErrorless Learning Mnemonics Cueing ChunkingMethod of LociSpaced Retrieval Face-name Recall Number Recall Story Recall List/Object Recall Procedural Memory Fluency Training Semantic ImpairmentsSTRATEGIES AND TECHNIQUES FOR COGNITIVE REHABILITATION 4 Difficulties with memory or cognition can often interfere with a person s ability to carry out specific tasks or activities; for example, the ability to recall peoples names, play cards, or use household appliances. In some cases, people may not have any specific area of concern, but may wish to address more general memory problems.

6 Interventions can therefore focus either on direct real-life, everyday situations or on more general rehabilitative a person identifies specific goals that s/he would like to work on ( related to the examples provided above), the TECHNIQUES in this manual can be applied to help the person to address these personal rehabilitation goals. In such instances, it can be beneficial to assist the person in eliciting goals either informally through discussion, or by using structured goal-setting approaches, like the Bangor Goal Setting Interview (BGSI; Clare & Nelis, 2012) or the Canadian Occupational Performance Measure (COPM; Law et al. 2005). These structured interview measures are used in research studies or clinical interventions to help elicit and rate progress with SMART Goals:When setting goals, it is helpful to ensure that those selected for intervention are Specific, Measurable, Achievable, Realistic, and time -limited.

7 The following areas/questions should be considered: 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:Goals might focus directly on the impact of COGNITIVE difficulties in life or some goals may have a broader focus ( socialising). Examples of goals might include: remembering the names of familiar individuals, remembering important numbers (PIN codes, phone numbers), developing and using a strategy to help remember important events or keep track of important personal effects, remembering how to carry out multi-component daily tasks, learning to use a memory aid such as a calendar or memory board, or learning and retaining personally relevant information.

8 Measuring Outcomes:If you wish to measure outcomes, it is beneficial to gather data at the beginning and at the end of the intervention. The BGSI allows for measurement of participant, carer and therapist ratings of performance and satisfaction for each goal identified. All ratings on the BGSI are taken before the intervention begins, and then repeated at follow-up to determine what changes have occurred. With some goals, it might also be appropriate to measure actual goal performance at baseline and follow-up. An example of this may be to record the number of correct responses on a test of face-name recall conducted prior to and after the intervention (see Clare, Wilson, Carter & Hodges, 2003). This allows for measurement of actual goal performance, to supplement self-ratings. STRATEGIES AND TECHNIQUES FOR COGNITIVE REHABILITATION 53. Guiding PrinciplesThroughout the rehabilitative intervention sessions, it is important to be aware of and to implement, where possible, the following guiding Dual COGNITIVE SupportCognitive impairment can affect peoples ability to use methods that aid encoding and facilitate retrieval.

9 It is important to consider how teaching STRATEGIES might provide support at both encoding and retrieval by ensuring compatibility of cues at encoding and retrieval ( category cues). Interventions for people with COGNITIVE impairment ; compared to healthy older adults, need to focus on more guidance and support when encoding material, extra learning trials, additional prompts, and cues for retrieval. Multi-modal encoding can be beneficial in facilitating later recall and is achieved by involving multiple sensory modalities during learning ( providing sound and smell cues to accompany the demonstration of an action sequence). Errorless LearningErrorless learning is an instructional technique that allows for the reduction or elimination of errors during learning. This is particularly useful in facilitating learning or re-learning of information for people with COGNITIVE impairment , as it minimises the number of times the person is exposed to an incorrect response (Clare, 2008).

10 To achieve errorless learning during CR sessions, regularly remind the individual that if they are not sure of an answer, to say either I m not sure or just don t respond. When this occurs, immediately provide the individual with a cue or prompt to assist them in recalling the correct answer. Effortful ProcessingIn some cases, when a person is asked a question, the more effort they are required to make in order to retrieve the correct answer ( the less prompts that are provided) the better. For example, research shows that high effort conditions (fewer prompts, more effort required) are more effective than low-effort conditions (given the answer immediately or given a lot of prompting) in facilitating cued recall of novel associations for people with COGNITIVE impairment (Clare, 2008). It may also be beneficial for face-name recall or number recall. To achieve effortful processing, at encoding - assist the individual to engage in elaboration of the to-be-remembered item at encoding get them to generate additional cues such as (i) the category that the item is in or a person that reminds them of that item; (ii) other related meanings that can be applied to the item; (iii) or think of the item in an elaborate setting (see also mnemonics); self-generated and more personal cues may be more effective than clinician generated cues.