Benefits of Cognitive-Motor Intervention in Mci and Mild to Moderate Alzheimer S Disease

Benefits of cognitive-motor intervention in MCI and mild to moderate Alzheimer disease

DESCRIPTION OF THE COGNITIVE-MOTOR INTERVENTION

(Additional material for the Neurology Web site)

Cognitive-motor intervention (CMI) was performed twice weekly in the mild-dementia units of two Maria Wolff day care centers. Sessions were carried out either in the morning or in the afternoon. Each session lasted 3.5 hours and each group had 7-10 patients. Groups were created according to the severity of dementia and personal affinities. For both therapeutic and methodological purposes, three main target areas were considered: 1) cognition, 2) socialization/mood and 3) motor function. Intervention techniques, session schedule and involved target areas are shown in table E-1. To reinforce structure and motivation, each month had a leitmotiv that inspired the contents of the different types of interventions (table E-2).

The content and characteristics of the CMI program were detailed and written down in a manual describing the 103 different sessions needed for one year of therapy. The manual was completed before the commencement of patient inclusion. Therapists used the manual to achieve the particular objectives of every session and to maintain constant and homogeneous effects of therapy across different groups and over several years of treatment. A general description of the sessions is given in the following paragraphs.

Welcome consisted of an unstructured chat that allowed latecomers not to miss orientation tasks. During the orientation task, each member of the group was given the opportunity to recognize himself as a unique individual (e.g., how do you feel today, name, place of birth, etc.). Later on, position in space was determined (e.g., participants drew a map of the itinerary to come to the center, different parts of the center were identified, etc.). Then time-orientation tasks were started (e.g., at what time did one wake up or came to the center, days of the week one comes to the center, last day one came, kind of cloths one wears to reveal season, etc.). Finally the group went through the most important news of the papers. The therapist helped the patients with clues according to their cognitive level.

Cognitive therapy (CT) (both individual CT and group CT) and training of activities of daily living (ADL) comprised the most demanding cluster of therapies. Cognitive therapy was intended to stimulate specific cognitive functions. Four out of 8 sessions every month were focused on memory and attention and the other 4 sessions were focused on other 4 relevant cognitive functions. Cognitive therapy started with individual exercises, usually deskwork. The next step consisted of participants doing cognitive exercises as a group (table E-3). Several strategies were used to stimulate the different cognitive functions. Attention was reinforced through verbal prompting and motivation. Memory was reinforced giving cognitive support at the time of acquisition and retrieval. Semantic processing was given priority in case of memory and language stimulation. Rehearsal and visual imagery were elicited during calculations. Visual imagery was also used to reinforce memory and visuoespatial capacities. Frontal/executive functions were addressed through problem identification, goal setting, generation of alternative solutions, decision-making and evaluation of consequences. Training of ADL was designed to adapt the pure cognitive work to ADL (table E-3). A level-of- assistance approach was used, including step identification, verbal prompting and modeling.

The coffee break allowed patients to rest and relate to each other in a spontaneous way. The therapist only intervened to achieve a warm and relaxed atmosphere among the participants (from qualitative research we know that this break is fundamental to the intervention). Later on, patients performed manual workshops linked to the month’s leitmotiv (e.g., Christmas handicraft in December, holiday collage in August). Patients at stage 5 in the Global Deterioration Scale (GDS) enjoyed workshops, specially if they could be performed with coarse psychomotor skills, whereas patients at stages 3-4 tended to reject individual manual workshops and preferred more complex psychomotor exercises.

Psychomotor therapy had a more sophisticated structure and technique. Therapists tried to integrate the previously stimulated cognitive functions through group-adapted motor exercises. Music was often used as an aid. Whereas the first part of the session aimed at cognitive and motor functions, the last part tried to induce a positive emotional state and to promote socialization. Patients at stage 5 in the GDS were proposed exercises involving body scheme perception, general coordination, static equilibrium and muscle tone (e.g., point to different body parts, move when music sounds and stop when music ends, imitate mate postures, stretch muscles holding a string). Patients at stages 3 and 4 were required to perform exercises involving laterality, dynamic equilibrium, eye-hand coordination and rhythm perception (e.g., imitate mate movements, walk on a line, throw and catch a ball, imitate rhythms with percussion instruments).