Summary: Results of a small trial show cognitive rehabilitation can help people with mild Alzheimer’s improve their ability to perform practical tasks. Unlike cognitive stimulation programs, cognitive rehabilitation is designed to improve specific skills. Rehabilitation may help people with memory loss stay functional and independent, but more research is needed.
Morris Friedell was diagnosed with Alzheimer’s disease in 1998. “I had a feeling that all I could do was wait for the axes to fall, one after the other,” the retired sociology professor wrote in his year 2000 essay “Potential for Rehabilitation in Alzheimer’s Disease.” “I’d lose my ability to drive, to budget, to speak coherently, to dress myself, to use the toilet. I thought: I must plan to die when I can still do so with dignity. I still believe that’s a meaningful challenge, but the greater challenge is how to live as fully as I can until that time. And that’s where rehabilitation comes in.”
A former sociology professor, Morris adapted techniques from traumatic brain injury rehabilitation programs and from psychotherapy to develop his own rehab plan. His efforts seem to have paid off, although it’s hard to know what led to his improvement. This is because Morris’s diagnosis is tentative, as are the diagnoses of many others with early stage dementia. “Since 2001,” he writes, “my neuropsychological testing has shown an absence of clinical dementia (although, in real life, conversations and TV sitcoms continue to move too fast for me). Perhaps my rehabilitative efforts have been more or less successful, or perhaps (despite the indications from PETs, MRIs and a qEEG) I never did have brain pathology, or even perhaps neither.”
Morris is running a bit ahead of science. Cognitive rehabilitation for dementia is a fairly new idea, and not much funding has been allocated towards research in this area. Maybe that’s because we tend to write off people with dementia.
Early Studies of Cognitive Rehabilitation Show Promise
“Until recently, there was an unfortunate bias that Alzheimer’s disease patients could not learn,” says Dr. David Loewenstein, director of research and neuropsychology at the Wien Center for Alzheimer’s Disease and Memory Disorders and professor of Psychiatry and Behavioral Sciences at the Miller School of Medicine at the University of Miami. In an article published in the American Journal of Geriatric Psychiatry in 2004, he and his colleagues described results of a trial showing that systematic cognitive rehabilitation can help people with mild Alzheimer’s disease carry out specific tasks.
In his study, twenty-five people with mild Alzheimer’s participated in twenty-four sessions of cognitive rehabilitation. They were trained in tasks including face-name association, object recall, making change, paying bills, orientation to time and place, and the use of a memory notebook.
Participants were tested on tasks similar to (but not the same as) those trained on at three points during the study: before rehabilitation, just after the twenty-four sessions, and three months after the sessions had ended.
With the exception of the bill-paying task, their performance on tasks similar to (but not the same as) those trained on improved significantly after rehabilitation. These improvements were maintained three months later. The study authors speculate that no improvement was seen in the bill-paying task because participants did well on this task before rehabilitation began, so there wasn’t much room for improvement.
While their ability to complete tasks increased, study participants’ scores on unrelated neuropsychological tests did not improve.
Everyone enrolled in this study was taking cholinesterase inhibitors, such as Aricept or Razadyne, but rehabilitation may also be helpful for persons with mild Alzheimer’s who are not taking these medicines. “Since the publication of the 2004 paper,” Dr. Loewenstein says, “we have done work that indicates that even those persons not on cholinesterase inhibitors benefit from the cognitive intervention program. We have not, however, conducted a controlled study examining the extent to which the effects of the cognitive intervention may have been augmented by different types of medications.”
There’s no research yet to indicate whether or not rehabilitation would help people whose dementia has progressed beyond the mild stage. “Our studies are on mild and very mild Alzheimer’s,” Dr. Loewenstein says, “and unfortunately at this time are not generalizable to moderate or severe Alzheimer’s disease.”
And what about aging baby boomers? Could rehabilitation help those of us who have problems finding the right word or navigating unfamiliar streets? It’s too early to tell, says Dr. Lowenstein. “Our program is dedicated to Alzheimer's disease, although we have an NIH grant proposal out looking at the effects of cognitive interventions on the abilities of normal elderly adults.”
Cognitive Rehabilitation – Not The Same As Cognitive Stimulation or Brain Fitness
Cognitive rehabilitation should not be confused with cognitive stimulation or brain fitness. Several companies offer cognitive stimulation programs, marketed mostly to healthy baby boomers hoping to stave off dementia. These typically involve memory exercises and games meant to ramp up overall brain activity. Some studies have shown that cognitive stimulation is useful for persons with mild Alzheimer’s, and I’ll write about these in another post. But cognitive stimulation is not the same as cognitive rehabilitation, which aims to improve performance on specific skills.
These differences were addressed in the University of Miami trial, where an additional 19 people with mild Alzheimer’s disease participated in twenty-four sessions of a “mental stimulation” program. The program did not focus on specific tasks, but instead consisted of interactive computer games involving memory, concentration, and problem-solving skills.
The group participating in the stimulation program did not show improvements in functionality comparable to the rehabilitation group, and in fact scored progressively worse in some tasks. “Directly trained skills showed improvements in the intervention group relative to the mental stimulation group,” Dr. Loewenstein says.
Working Around Memory Loss
As with Morris Friedell, rehabilitation for brain injury was a starting point for Dr. Loewenstein. “Dr. Amarilis Acevedo and I developed the cognitive rehabilitation paradigm because we had been successful rehabilitating stroke and traumatic brain injury in our outpatient treatment center,” he says. But unlike Morris, they did not find brain injury rehabilitation techniques to be helpful. “Unfortunately, the existing cognitive and functional treatments for these conditions were not useful for Alzheimer’s,” he says. “The cognitive and functional interventions that we use with Alzheimer’s disease patients employ different learning strategies.”
Just what are those strategies? The University of Miami researchers tested a combination of three specific techniques for rehabilitation of people with mild Alzheimer’s:
- Spaced retrieval – a method of learning in which the time between learning information and retrieval of information is progressively increased. The goal of spaced retrieval is to help people remember information over long periods of time.
- Dual cognitive support – in this technique, cues or ways to remember information are provided both when the fact is learned and when it is remembered or retrieved.
- Procedural memory training – a method in which tasks are practiced repeatedly, rather than trying to memorize the steps necessary to complete those tasks. This technique takes advantage of the fact that although persons with early stage Alzheimer’s may have problems with explicit memory [knowledge of facts, knowing what happened when], they tend to retain their implicit or procedural memory [unconscious knowledge of how to do something; skills]. Using this preserved procedural memory may be key to cognitive rehabilitation.
“What cognitive [rehabilitation] interventions provide is a way for Alzheimer’s patients to take preserved skills (implicit memory, procedural knowledge, motor memory) and apply them to work around cognitive and functional deficits,” Dr. Loewenstein explains.
The actual exercises used in the University of Miami trial were:
- Learning face-name associations using spaced retrieval and dual cognitive support
- Practicing time and place orientation using a calendar and other parts of a memory notebook during rehab sessions and at home
- Manipulating objects as though participants were using them (procedural memory training)
- Pressing mouse buttons in response to various shapes and information that appeared on a computer screen
- Making change for a purchase from a $20 bill
- Paying bills and balancing checkbooks.
“A take home message from our research is that cognitive and functional rehabilitation in early Alzheimer’s should target meaningful real-world cognitive and functional skills by using procedures that bypass the episodic memory deficit (e.g., procedural learning, spaced retrieval),” Dr. Loewenstein says. “The potential for keeping older adults functional and independent for longer periods of time is quite exciting.”
The basis for the improvements seen from cognitive rehabilitation is not clear, he explains. “A number of people tout brain plasticity, but there is no evidence at this time that cognitive rehabilitation affects plasticity in the Alzheimer’s brain and it would be difficult to argue that any biological process in the brain is altered.”
Dr. Loewenstein and his colleagues are now conducting a much larger cognitive rehabilitation trial as part of the Florida Alzheimer's Disease Research Center funded by the U.S. National Institute on Aging. “A number of the same techniques in the original study are being employed,” he says, “but we have also focused on more functionally relevant tasks for very mild Alzheimer’s patients including using an ATM machine, using automated telephone menu systems (interacting with a utility company) and even doing simple searches on the internet.” Although this is a five year study, he hopes to have some initial results to report in twelve to eighteen months.
Participants receiving cognitive rehabilitation in the previous study continued to show improved performance in the tasks tested three months after rehabilitation ended. But researchers don’t know how long after that the benefits might last. “In our current studies, we include booster sessions after the initial treatment (two times per month) for six months in an effort to maintain treatment gains. We would like to obtain funding to study the effects of longer booster sessions” says Dr. Loewenstein.
Researchers at the University of Wales are also conducting a trial of cognitive rehabilitation for early stage Alzheimer’s. The trial includes fMRI imaging to help them understand how rehabilitation affects the brain.
Will Your Doctor Write a Prescription for Cognitive Rehabilitation?
Will doctors eventually write prescriptions for cognitive rehabilitation for people diagnosed with dementia? “I think that this is premature at the time given that this field is in its early stages,” Dr. Loewenstein says. “I believe that the future for cognitive and functional rehabilitation is bright and promising but I think that we need more evidence for effectiveness before these types of interventions are considered for clinical practice.
But I would say that we have poured billions of dollars into pharmacological agents that often have very modest cognitive and functional benefits. I think that it is appropriate to study and to develop cognitive approaches which may have even greater impact on certain functional skills and capacities.”
In the meantime, Morris Friedell continues his own rehabilitation program. “I believe that an important reason patients go downhill the way they usually do is because society sends them a devastating message that their lives are already over,” he writes. He has chosen to reject that message, and is working towards his vision of “recovery of autonomy, competence and quality of life after diagnosis with dementing disease.”