September 2010

Sharon Gaskin, MS, OTR/L, Occupational Therapist
Contact info:

Inova Fair Oaks Hospital, Physical Medicine & Rehabilitation Department
3600 Joseph Siewick Drive, Fairfax, VA 22033
703-391-3642
www.inova.org

Sharon gave us a handout with the key points of her presentation about cognition and improving function.

Cognition
Neuropsychological investigations show significant indications that there is a relationship between cognition and PD. Three areas of cognition are: attention, memory and executive functions Sorting and planning tasks are examples of executive functions.

Attention
We need to focus initially, then sustain what we’ve heard.
Selective – not letting yourself be distracted (e.g. listening to a speaker and not be distracted by someone walking by)
Alternating – can you switch back and forth between 2 things (e.g. while working in the kitchen, someone reminds you about a coming appointment)
Divided – can you truly keep your full attention on 2 or more tasks at the same time (e.g. drive & talk on cell phone) While driving, it’s actually easier to talk to a passenger in the car than to someone on the cell phone. This is because the passenger is aware of the situation you’re both in and will adapt (e.g. stop talking if you need to concentrate on the road).

Memory
7 numbers is about our working memory 
Grouping numbers helps us to remember them (e.g. phone numbers)
Short term memory – about a 5 – 10 minute time span
Long term memory – Most people don’t have a problem with long term memory because these memories tend to stick.

Executive functions
This area is the toughest one to work with and it involves our self-awareness. Tells us when we’re feeling scattered about doing things. Helps us organize things and set goals. It’s our inhibitor because it keeps us from saying things we really shouldn’t and helps us with initiation such as wanting to do something.

Improving Function
Attention:
1st step – if you can’t pay attention you won’t remember things An Occupational Therapist works with helping people who want to improve their attention so they can do things they couldn’t do as well or as safely as before (e.g. keeping appointments, remembering names/faces)

Card game to practice skills
Start by choosing one card from each suit and placing them face up on the table. Use cards that don’t have the letter “e” in the name (e.g. ten, ace, queen)  Sort the rest of the cards by suit, placing cards with letter “e” face down on the piles while all other cards are placed face up. This involves 2 tasks and there should be no errors. Practice and aim to complete the task quickly.

www.lumosity.com has lots of brain games. You can start with a free trial but be prepared to pay monthly fee.
A couple of examples of the kind of games you can play: 
1)  bird watching – Has a target that you have to keep your focus on. Another bird flashes on the screen and you have to move your mouse to where the bird flashed.
2)  bird migration – Shows V-shaped group of birds. You pay attention to one bird that sometimes goes in the same direction as the other birds and other times it doesn’t, and you need to ignore the other birds. As quickly as you can, you’re supposed to identify the direction of that one bird.

Some strategies that can help:
• highlight things that are important
• slow down
• use your finger to follow what you’re reading
• talking aloud will help you focus
• a digital recorder to take notes

Improving your memory is an active process. What is the problem? What can you do when the system you were using is no longer working?

Memory:
external strategies

What changes can we make to the environment? (e.g. digital recorder)
• using lists for shopping, meeting dates
• post-it notes – (e.g. on the door to remind you what to take with you when you’re going out) or painter’s tape (doesn’t stick to the wall permanently)
• to remind you about meetings, (see also association strategies)
• before you go out, put the things you plan to take with you by the door
• enlarging things (e.g. writing the first letter “e” instead of “egg)
• calendar – highlight doctor’s appointments in red Other strategies that don’t involve writing with a pen:
• use different devices like a tape recorder, paging systems, vibrating or alarm watch to remind you when to take medications
• a talking calculator gives feedback so you know you entered the correct numbers
• for keys – a wireless object device where you push a button and an alarm on your keys will help you to find them
• If you leave your reusable bags in the car instead of taking them into the shop, try keeping them where you’ll see them when you get out of the car
• routines
• answering machines – Leave yourself a message by calling your home phone using your cell phone.

Internal strategies
Grouping and association 

Activity – Sharon divided the room into two groups read a different list of words for each group. We had to remember them and write them down. The side that were given a list of fruits and vegetables got more right because they were all associated together. The other side had odd, unassociated items that were harder to remember (e.g. milk, box, elephant, pencil, scissors, knife, pocketbook, envelope)
Pegging – What if you needed 4 things from the grocery store e.g. broccoli, dishwashing liquid, bananas, soup. Instead of trying to remember the 4 items, make a list of the first letter for each word B_B_D_S (similar to association strategy). It works even better if the letters can form one word for you to remember.
Loci – A strategy to use places to remember things. Imagine putting the things you need to remember in the room that they would belong in, in your house.

External strategies may be more effective than internal strategies.   

Executive functions strategies
• a family member can pre-organize to help the person having difficulty
• limit your choices
• do important tasks at peak times
• use time marking – If there are problems with time awareness, someone with difficulty may not be aware of how long it takes to complete a task. Use a kitchen timer for awareness of sense of time
• set manageable goals
• brainstorm – to find different ways to come up with solutions – the answers don’t have to be correct as long as the person is thinking
• re-examine the problem in a different way

One couple uses a big wall calendar in the kitchen that they review their activities for the coming week every Sunday night. It takes them from short term thinking to long-term thinking.

Question: What can you do if you hear a question but you’re slow to respond? This may be because you’re processing the question. Attention exercises can help and it helps to deal with one thing at a time (part of executive function)

Resources for some examples from above plus much more:
www.goldviolin.com – wireless object finder
www.bindependent.com – talking calculator, step pad
www.epill.com – vibrating 12 alarm pager

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