Alzheimer’s in everyday functioning. Considering the current prevalence

Alzheimer’s
disease (AD) is the most common form of dementia, the onset and progression of which
follows a specific characteristic pattern. Neuropathological changes in the
brain in AD are manifested through impairment in different cognitive
functioning such as attention, memory, information processing, language,
comprehension and executive functioning along with a range of activities of
daily living. Specific criteria for
diagnosing Alzheimer’s disease defined by NINCDS-ADRDA (1984) are progressive
decline and untimely loss of multiple cognitive functions including impaired
ability to learn new information or to recall previously learned information, loss
of comprehension ability, Loss of ability to perform complex tasks involving
muscle coordination, Loss of ability to recognize and use familiar objects, Loss
of ability to plan, organize, and execute normal activities. These problems
represents substantial decline from previous abilities and cause significant
problems in everyday functioning. Considering the current prevalence rate, AD
increases with age from about 0.5 percent per year at age 65 to 69, 1 percent
per year from age 70 to 74, 2 percent per year from age 75 to 79, 3 percent per
year from age 80 to 84, and 8 percent per year after age 85. About 13 percent
of the U.S. population over age 65 is affected by Alzheimer’s disease. In 2007,
this was more than 5 million people. And with the aging of the population,
projections estimate that, by the year 2030, 7.7 million people will have
Alzheimer’s disease. Prevalence of dementia has been shown to be lower in
populations in India, China, and Nigeria. Given the high prevalence in older
age and advancing age of the population, Alzheimer’s disease is a growing
problem affecting the personal, occupational and social lives of not only the
sufferers, but also their families. However, treatments are limited to
symptomatic relief and modest delays of progression.  

As
the illness progresses, there will be greater functional impairment and greater
dependency needs of AD patients. The attendant loss of independence may be very
difficult for Alzheimer’s disease sufferers to accept, especially if there is
agnosia and a lack of insight into their deficits and impairment.   

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When
it comes about the treatment of Alzheimer’s disease, several researches have
been conducted so far based on the efficacy of pharmacological treatment in
improving cognitive decline in those patients. Though the effectiveness of
cognitive retraining has been neglected and not explored in Kolkata.

Cognitive
rehabilitation

Neuropsychological
rehabilitation can improve insidious decline in various cognitive, personal and
functional aspects of geriatric population However, people with AD may have
difficulty to responds in cognitive treatments due to their denial of memory
deficits, poor self-awareness, inability to accomplishing daily tasks, lack of
motivation, hopelessness, and apathy, all of which may be either due to the
illness or be secondary to depression. Cognitive rehabilitation training
exercises are also labor intensive and, unfortunately, serve as a repeated
reminder about the memory impairments and attendant functional consequences. In
order for cognitive rehabilitation methods to be effective, patients must be
adequately engaged and motivated to not only begin a rehabilitation program but
also to remain involved in the intervention until a therapeutic dosage can be
attained. We review approaches to cognitive rehabilitation in AD,
neuropsychological as well as psychological obstacles to effective treatment in
this population, and methods that target adherence to treatment and may
therefore be applicable to cognitive rehabilitation therapies for AD. The goal
is to stimulate discussion among researchers and clinicians alike on how
treatment effects may be mediated by engagement in treatment, and what can be
done to enhance patient adherence for cognitive rehabilitation therapies in
order to obtain greater cognitive and functional benefits from the treatment
itself.

 

Method

The present study was conducted at a well known day
care centre for Ad and related disorders in the city of Kolkata. Five patients
were selected by the centre according to the inclusion and exclusion criteria
of the study plan submitted to the centre by the researchers.  Initially families of five patients were
approached by the centre and written consent was obtained by the centre of
behalf of the researchers. Consent was obtained from the family members of the
four patients but finally the neuro-psychological assessment and cognitive
retraining was done on two of the AD patients. It was not possible to execute
the training programme on the other two patients due to deteriorating health
condition as well as increasing behavioural problems. The study was done after
the study plan was approved by the University Committee of Research Ethics.

Participants:

The participants of the study consisted of two
patients with AD of moderate severityelected from the patients attending
daycare centre ARDSI in Kolkata. Both the patients belonged to the educated
upper middle class society and currently lives in Kolkata.The premorbid history
of both the patients suggest that both of them were significantly functional in
social, occupational and personal life until the onset of the current illness.
Both the cases are briefly presented below:

Case1:

Mr.A, a 69 year old married retired engineer from a
public sector telecom company diagnosed with dementia of Alzheimer’s type for
more than one year was recruited for the current cognitive rehabilitation
programme. The family history of the patient suggests that the patient
currently lives with his wife in Kolkata and his only daughter is married and
lives abroad.History of the patient as suggested by the record file at the day
care centre suggests that the patient’s primary complaint consisted of
difficulty in remembering and decision making. Previous psychological test
report suggests a MMSE score of 12,ACE-R score of 44 and CDR score of 2.MRI
report of the patient suggests cerebral and cerebellar atrophy. Other medical
report suggests presence of hypertension, hyperthyroidism and diabetes
mellitus(controlled).

Case 2:

Mr.B, a 89 year old retired Air force personnel
diagnosed with dementia of Alzheimer’s type for more than one year was
recruited for the current cognitive rehabilitation programme. The family
history of the patient suggests that the patient currently lives with his elder
son his family in Kolkata and his only daughter is married and lives in Delhi.
Patient’s primary complaint consisted of difficulty in remembering things,
difficulty in maintaining daily life activities of his own. MRI report of the
patient suggests cerebral and cerebellar atrophy. Other medical report suggests presence of hypertension,
hyperthyroidism and diabetes mellitus(controlled).

Tools Used:

Assessment Tools:

Training Kit:

Procedure:

The study was conducted in three phases. The two
patients selected for the study were initially assessed with cognitive
screening tool and other neuropsychological tools. Before beginning the
neuropsychological assessment the diagnosis of AD was confirmed by the
attending psychologist following the international diagnostic criteria of
NINDS-ARDRA on the basis of mental status examination and case history provided
by the centre (caregiver reports and case record file).After the initial
assessment was completed the training programme was initiated. The training was
conducted over a period of six months. A total rehabilitation of  … hours were provided to each of the
patients. Initially, for a period of one month a training of 120-180 minutes
was conducted per day, with intermittent time gaps. From the second month
onwards training session was adjusted to a period of 90-120 minutes. Tasks were
selected from the five modules of the Brainwave-R based on the cognitive ability
of each patient. One task was introduced at a time and the introduction of a
new task was deferred until the patient could perform sufficiently well in the
first task. Each module was administered over a period of two weeks. Any task
found difficult by the patient or found unsuitable for the patient was
eliminated from the training. In total … sessions were provided. At the end of
the training period, the post training assessment was done

            The
details of baseline and final assessment along with the details of cognitive
rehabilitation training programme is outlined below:

Baseline Assessment:

 

Cognitive
Rehabilitation program:

DOMAINS

TASKS

DESCRIPTION

ATTENTION

Paced Random Number

The
subject has to circle the number 2 in the worksheet, when he hears the number
2 being read aloud among the random selection of numbers.

Random paced Words

The
subject has to circle the word TREE in the worksheet, each time he hears the
word TREE being read aloud with a random selection of words.

Paced Random Letter

The
subject has to circle the letter B in the worksheet, each time he hears the
letter B being read aloud with a random selection of letters.

Word Targeting

Here,
each time the client hear the word THE, he has to circle it in the worksheet

Categorizing Random Words

Each
time a word is read, the has to look at the worksheet and put a check mark
under the heading that best describes the category to which he/she thinks the
word belongs. Three categories are there. Tree, shapes and Animal.

VISUAL PROCESSING

Alphabet Scanning

Subject
has to read aloud the first letter at the top of the left hand column and
then read the first letter of the right-hand column. Continue doing until he
/ she get to the bottom of the column.

Letter cancellation

The
subject has to put a circle around the letter N, every time the subject would
see letter N among many letters in two sheets. 

Grid Multiplication

 

Shape Matching

Find
the similar shapes, one from the left and one from the right side of the page
and label them with same number

Number Search

The
subject has to read the number word on the left side of the page. And circle
all the numbers that are the same as this word, on the line next to the word.

INFORMATION
PROCESSING

Shape Matching

Subject’s
task is to find the shapes that are the same and color the shapes with one
color that are the same in shapes.

Sorting

Clients
tasks is to sort the shapes by size and coloring the small, medium and large
shaped figure by three different colors

Flashcards

Every
time the subject finds a word, end with …ing , he has to copy it in large
letters onto the sheet of paper given to him, next session onwards , he/she
has to read aloud the words as fast as he/she can

Copycat

Instructor
would make some target movements, after watching those carefully, the subject
has to imitate it as fast as he/she can

Number Sequencing

The
subject sees that a sequence of numbers has been started and he /she have to
continue the pattern across to the right side of the page in the correct
sequences.

MEMORY

Memory Strategies 1

4
stages of memory process will be explained to the subject…. And he has to
fill the blanks type questions related to the ways of improving attention,
encoding, consolidation and retrieval.

Memory Strategies 2

Subject
will be explained use of some memory aids with which the person with memory
impairment can be helped to accomplish some daily life activities.

Word List

A
list of 10 words has to be read aloud and subject has to remember those using
the cues that examiner will give him. This is an exercise allowed to write
anything down.

Card Matching

 

Object Recall

A
tray with 8 objects will be shown to the subject and subject has to memorize
within 2 minutes. Then two items will be removed and the tray will be shown
again and the subject has to say which items have been removed.

EXECUTIVE FUNCTIONING