Dementia Care

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Vol 5 No 5 October/November 2016 Australian Journal of Dementia Care 37
Adefining feature of dementia is the
presence of cognitive or
behavioural symptoms that are
severe enough to interfere with a
person’s ability to independently carry
out their usual activities of daily living
(McKhann et al 2011).
Within the World Health
Organisation’s framework, the cognitive
and/or behavioural impairments of the
person with dementia lead to disability in
relation to the person’s capacity to
perform specific daily activities, and to
participation restriction in the context of
everyday life and roles (WHO 1998).
A biopsychosocial framework of
dementia (Clare et al 2012a) emphasises
that the underlying brain pathology does
not solely determine the overall level of
functioning. Even when underlying
impairment cannot be addressed, some
barriers to activity and participation can
be removed, and overall experience of
dementia improved, by appropriate
management of personal, social and
environmental factors.
Along with an increasing emphasis on
the primary and secondary prevention of
dementia, there is growing recognition of
dementia as a chronic health condition
(WHO 2012) with the implication that
those with a diagnosis and their families
require ongoing support in managing the
effects of the illness. This recognition also
underscores the importance of applying
person-centred principles to the support
and care of people with dementia, to
maximise their agency and autonomy,
dignity and well-being.
An enablement approach
to dementia care
In line with a person-centred approach to
dementia care we are advocating that an
enablement philosophy should serve as
the organising framework for the care and
support of people with dementia (Clare
2016). Rather than focusing on disability,
an enablement approach focuses on what
the person with a disability can do with
appropriate support, and encourages
engagement, shared decision-making and
facilitation of factors that promote optimal
participation in meaningful life activities
in context.
Cognitive rehabilitation
Cognitive rehabilitation (CR) is an
individualised, person-centered
approach, in which people with cognitive
impairments, their close support network
and healthcare professionals work
collaboratively to identify personally-
meaningful and achievable goals couched
in everyday activities, and then use
evidence-based strategies (compensatory,
restorative, or both) in pursuit of these
goals. CR is distinct from the general
Cognitive Stimulation approach (Woods et
al 2012) (described in the article on p42) in
that it addresses individual needs and
challenges to enhance independence in
day-to-day activities, and from cognitive
training in that it does not aim to improve
cognitive abilities per se (Clare et al 2003a).
CR has mainly evolved fromwork with
people with acquired brain injuries (ABI),
such as traumatic brain injuries, and
stroke, and was designed to help people
with cognitive impairments re-integrate
into their previous life context (Wilson
1997) . However, as argued previously
(Clare et al 2003b) the principles that
underpin CR for people withABI are just
as applicable when it comes to people
with dementia.
Cognitive rehabilitation in practice
Unlike the case for people withABI,
within the context of dementia caused by
progressive neurodegenerative conditions
like Alzheimer’s disease (AD), goals will
inevitably need to change to
accommodate further decline in function
as the disease progresses. Ideally, CR
should be offered soon after the diagnosis,
when dementia is of mild severity, as early
intervention provides an opportunity for
advanced planning, and to capitalise on
the person’s residual cognitive strengths
and relatively circumscribed functional
limitations.
When applied early, CR may also
contribute to a sense of hope to the
affected person and their family members
that something can be done to allow them
to live better with dementia.
With disease progression, maintaining
basic practical skills and engagement in
conversation may provide a focus when
working with individuals with moderate
dementia. In the later stages the focus may
shift to enabling expression of preferences,
with an emphasis on optimising well-
being and maintaining dignity.
Drawing on the results of a
comprehensive assessment of the person’s
cognitive and behavioural functioning,
their psychological adjustment and
coping styles, and the support available to
them, the CR specialist will typically work
with the person with dementia and close
others to identify a number of potentially
achievable goals related to their day-to-
day function.
Importantly, goals will generally not be
framed in terms of a cognitive process (eg,
‘I want to improve my memory and
attention’), but in terms of relevant daily
activities (eg, ‘I will only discuss socially
appropriate matters with the friends we
meet with for lunch once a fortnight’, or ‘I
will check upon delivery that all the
groceries arrived as ordered through the
online delivery service’).
The CR specialist can be any healthcare
professional with suitable clinical training,
qualifications, and experience in brain-
behaviour relationships and intervention
delivery, and may or may not be the
person doing the actual routine work with
the affected person and their family. In
Australia, clinical neuropsychologists are
uniquely positioned to act as CR
specialists but other professionals,
including occupational therapists, clinical
psychologists, and speech-language
therapists may also have the relevant
training and experience to engage in CR
work, possibly with the support or
supervision of an experienced
neuropsychologist.
The person with dementia and
members of the close support network
will then be guided to use a range of
evidence-based techniques that have been
demonstrated in carefully designed
studies to support learning and re-
learning of information among people
with dementia (see ‘Learning with
dementia’ p38)
What is the evidence?
To determine whether or not there is
compelling evidence for or against a
particular treatment or intervention it is
DCRC SPEC I AL I SSUE : THE B I G P I CTURE I N DEMENT I A RESEARCH
Cognitive rehabilitation for people with
dementia: what is it and does it work?
Alex Bahar-Fuchs, Aleksandra Kudlicka and Linda Clare describe how cognitive rehabilitation can
be used as part of an enablement approach to support people with dementia, and their families,
maintain better quality of life and independence