MSL February 2019, feature 2

Medical researchers in the field of dementia are far closer to a prevention than a cure.

As mixed as these blessings are for the healthy and afflicted, the explorations into cognitive fitness are now peeling away seemingly endless layers of mystery cloaking this dreadful disease. In the process, they are energizing the rehab community with equal amounts of hope and vigor.

In memory care, the tools of the therapy trade often have been a mixed bag. Literally. That’s what Laura Mock remembers as a novice therapist years before joining IN2L as the company’s customer success manager.

“When I started in the field of therapeutic recreation, I would spend 10 minutes setting up, not including the planning beforehand, for a specific resident. And often, for whatever reason, they were not into it,” Mock recalls. “You had to be pretty good at punting and being flexible.”

Those frustrations soon prompted Mock to come to her therapy sessions with “armloads and carts” full of therapy tools in hopes at least one of them would light a resident up.

Fast forward to now, and the task of finding that spark in a dementia-clouded mind still is hit or miss for Mock and other therapists. But thanks to research and the problem-solving moxie that memory care therapy now demands, there are more hits than misses.

Mock attributes that fact to better technology and her years of experience treating dementia.

“Finding what an individual responds to is always the way to provide interventions for success,” says Mock, a certified therapeutic recreation specialist. “My mantra is simple: If you make it fun or something they are interested in, they will participate. I’ve often been able to get residents working on strength and endurance to stand longer than my counterparts in physical therapy. How? Standing in parallel bars for five minutes is ‘yawnsville.’ How about standing while we play one a resident’s favorite games, like ‘Kings in the Corner,’ at an elevated bedside table?”

Brain games

Some may find it difficult to reconcile the seriousness of dementia with anything labeled “fun,” but that is precisely what research now has identified as a powerful therapeutic weapon. Two fairly recent studies show why and how.

In a 2010 study published in the Journal of the American Geriatrics Society, researchers set out to find how to prevent agitated behaviors among nursing home residents with dementia. In the process, they found that “structured activities, which range from trivia games to puzzles, have also been shown to have a positive impact.”

A year later, researchers, in a study published in The Journals of Gerontology, identified what they believed to be a link between cognitive stimulation and functional decline in Alzheimer’s disease, echoing the benefits of what earlier efforts had found in “later life engagement in intellectually and socially stimulating activities” such as crossword puzzles and card games.

In short, research has shown conclusively that interventions such as brain games can be a contributing factor in preventing dementia.

“There is growing clinical evidence that targeted cognitive stimulation / rehabilitation may be beneficial in improving baseline cognitive performance and offering protective qualities related to future cognitive status,” says Robert Maxwell MA, CCC-SLP, regional clinical director for Genesis HealthCare and chair of the Genesis Rehab Services Dementia Special Interest Group.

“Research has shown that when people keep their minds active with brain games such as puzzles, trivia and problem-solving activities, they are less likely to develop signs and symptoms of dementia,” notes Sarah Ziegler OTR/L, occupational therapist at Emerald Crest by Cassia, a ministry of Augustana / Elim Care. Their Learning Lab for Eldercare Technologies received a Silver Award in the senior living track of the 2018 McKnight’s Excellence in Technology Awards.

Unlike others, however, Ziegler is not convinced that brain games and other forms of mental stimulation can ward off a dementia or Alzheimer’s diagnosis, saying, “If someone is predisposed to the diseases that cause dementia, these types of activities may only delay the onset.”

“Research data have been reliable and consistent enough to force care providers and the senior living space out of their horribly old cone-stacking, pegboard habits,” says Paul Riccio, vice president of finance and development for Vertis Therapy. Riccio views this new “professional burden” as a positive step toward therapists’ shared quest of knowing how to truly connect with their patients.

Although it is difficult to identify precisely when this conclusion around prevention was reached, Riccio traces it to SAIDO Learning, a working memory training program developed in Japan. SAIDO uses systematized basic problems in arithmetic and language, including reading aloud, as well as writing.

“SAIDO objectively proved this and has held up to scrutiny that brain games absolutely aid in the prevention of dementia,” Riccio says. A multi-year study identified four categories of so-called “brain games,” a greater variety of which seem to directly correlate with greater success in prevention, he added.

A clue might be found in the brain’s neuroplasticity, or ability to form new connections, says Kathleen Weissberg, OTD, OTR/L, CDP, CMDCP, education director for Select Rehabilitation. “Anytime you learn a new skill or practice a skill, your brain develops new connections,” she says. “The more you use the connections, the stronger they become.”

Another clue may be found in the brain’s work in sequencing, says Maria Oliva, chief operating officer of Chicago-based Pathway to Living, a Chicago-based senior living provider. “Games that require sequencing are the most successful. Using repetition and procedural memory allows people with dementia to relearn or learn new tasks,” she says. Other interventions should focus on daily living tasks like cooking and folding clothes.

Interventions abound

Therapists often used the term “interventions” to describe what is a “break in routine” to the layperson. And when it comes to memory care, a number of interventions are showing tremendous promise in delaying the onset of dementia, if not preventing it altogether.

Christopher Krause, director of rehab at IN2L, believes interventions of all kinds – from social participation and well-being, to engagement, mental health and cognition – can help ease the journey of living with dementia, and he said he has witnessed firsthand the most profound effect in residents with dementia who are in the later stages of decline.

Early successes also are being discovered in robotic therapy, according to Tom Canterino, co-founder and vice president, business development and B2B sales, Ageless Innovation. Companion robotic pet therapy is a nonpharmacologic therapy that consists on the use of robots as an element of play and company, he adds.

Weissberg believes the best intervention of all is normal, everyday activity, or “things that are familiar and things that bring enjoyment.” She also mentions the Montessori Method, which uses everyday activities to successfully engage those with dementia.

Others believe in a holistic approach.

“A memory care therapist’s role is to be focused on the whole person through active, therapeutic, nonpharmacologic interventions,” says Jennifer LaVoi OTR/L, director of cognitive care at Emerald Crest by Cassia. “The therapist utilizes a whole host of approaches including reminiscence, reality orientation, physical activity / exercise, sensory stimulation and aroma therapy.”

Christy Kyrus, a recreation therapist with Sentara, a large healthcare provider, says her associates have had success with a program called LEAP, a dementia specific sensory program. “We use a lot of different interventions in that program, such as recalling, reminiscing, and music and aroma therapy, and we even have sensory lights in the room that mimic the sky,” she says. “These have value because they utilize cognition, long-term memory and short-term memory and stimulate the senses for relaxation.”

The power of connection

Memory care technology companies are among a growing list of entities that are passionate about the link between engagement and improved cognitive health.

Charles de Vilmorin, CEO and co-founder of Linked Senior, conducted more than 400 interviews in 2018 to distill what he believes are the necessary ingredients of engagement. He says many providers are only partly successful engaging all of their residents by “providing a stimulus and occupying someone to create an outcome. What’s missing is a sense of purpose — the idea of engaging people and helping people find purpose regardless of their age, who they are and where they are cognitively. People dying today can still find a purpose until their very last minutes of their lives. That is what engagement is about.”

Connected Living’s platform is built around the premise of social engagement as a recipe for both cognitive and physical health. For memory care residents, regaining some measure of control is paramount, says Sarah Hoit, CEO and co-founder.

Connected Living recently incorporated the Amazon Alexa voice assistant into its digital and mobile platform and views it as a vital, emerging intervention. “I think we’ve been at the forefront of bringing voice to our residents in communities,” she says. “Alexa can ask to share music with the family or find out what is on the menu. She is a constant companion when others are not there.”

Erum Azeez Khan, CEO of SoundMindIntelligence, believes voice assistants such as Alexa can access information and content to help with memory recall rather than having to reach for an iPad or smartphone. InspiredMemory Care, a client, uses voice assistants, under Kahn’s supervision, to play music and show videos (through the Echo Show device) to assess what capabilities someone with dementia has to recall certain songs and images. Caregivers also easily can call other rooms to request help simply by speaking, so they can stay in the moment when providing care, Khan adds.

“Our focus in using technology is often on overcoming learned helplessness and promoting engagement that empowers the individual living with memory impairment to connect in a strengths-based way,” adds Nettie Harper, MSRS, CTRS, COTP, co-founder of Inspired Memory Care.

A reminder about assessments

“When looking at the memory care therapist’s arsenal today, the most important component is the use of a standardized cognitive assessment,” says Beth Reigart, MPH, OTR/L, a clinical operations specialist for Functional Pathways. Reigart favors the Brief Cognitive Assessment Tool, or BCAT, which can provide a means to capture early onset changes leading to decline in function and safety for the individual.

Pam Brooks, OTR/L, clinical occupational therapy specialist for Centrex Rehab, echoes the value of assessments.

“Knowledge of an individual’s cognitive level through interdisciplinary assessments and team consultations allows you to identify interventions for best approaches, interactions, decreased behaviors and promoting successful and realistic participation and function,” she says. “Patient-centered interventions focus on meaningful activities. If the individual was a homemaker, for instance, ask them questions related to homemaking.”

‘Breakthroughs’ in activity therapy?

Vertis Therapy was one of several providers that participated in a nationwide rehab therapy program pilot using the MicrosoftKinect, a motion-sensing camera used widely in newer-generation XBOX games.

The pilot showed Riccio just how new technology is being used to prompt dementia residents to do familiar tasks while unmasking their life story, “or what I call muscle memory.” This is one example of how the Kinect was used in gamified therapy keep Alzheimer’s at bay.

To Riccio, it illustrates the stark contrast between low- and high-tech approaches to treating the disease.

“For some who have worked in dementia rehab, low-tech means taking a box full of screws, emptying it on a table and going, ‘Uh oh. Can you sort these, Bill?’ ” Riccio says. “Next thing you know, he’s doing occupational therapy and doesn’t even know it.”

High-tech efforts with tools such as Kinect are revealing new possibilities. “They basically changed the games 10-year-olds had into something an octogenarian would enjoy and used that high-tech camera to physically and accurately measure things such as weight bearings and the angles of 32 different joints,” he said. If anything, the Kinect experiment provided an invaluable measuring tool dementia rehab therapists could use without interrupting the cognitive therapy portion of care, Riccio added.

Linked Senior recently completed a large research study with Baycrest that successfully reduced antipsychotic use by 20% while simultaneously boosting engagement activities in mid- to high-level dementia residents. Among other results: An 18% decrease in aggressive behaviors, 20% increase in social engagement and 3% increase in cognitive functioning.

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