Dementia Care

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Vol 5 No 5 October/November 2016 Australian Journal of Dementia Care 39
extensively to support a range of
compensatory strategies (eg, reminders,
organising activities, recording
important information, etc.) While
computerised cognitive training to date
has been criticised for being abstract and
removed from real-world activities, the
emergence of function-led and
individually-tailored virtual reality
applications has the potential to
challenge existing distinctions between
cognitive training and cognitive
rehabilitation (Parsons et al 2015; García-
Betances et al 2015).
Dementia prevention
Cognitive rehabilitation as an
intervention strategy need not be
restricted only to people with established
cognitive and functional impairments.
The enablement philosophy at the heart
of CR can and should be extended to
individuals at risk of dementia, including
people with mild cognitive impairment,
as well as cognitively healthy adults with
lifestyle, health-related or even genetic
vulnerability for dementia.
While cognitively healthy older adults
and people diagnosed with mild
cognitive impairment do not usually
exhibit significant functional disability,
many individuals in these groups will
nonetheless identify functional areas in
which they would like to do things more
effectively or in a way that might
facilitate the development of ‘cognitive
reserve’ – broadly defined as the
individual’s ability to continue
performing daily tasks successfully
despite accumulating brain pathology
(Stern 2002). For example, healthy older
adults with a tendency to misplace
objects might be assisted to develop
habits that reduce the likelihood of losing
personal belongings, especially given
that it is likely to be more difficult to
form such habits in the face of cognitive
impairment.
Outcome measures
An important challenge in evaluating the
efficacy of highly individualised
psychosocial interventions, including
CR, is that there typically is not a single
agreed upon or objective ‘metric’ against
which efficacy is evaluated. Also,
because the outcomes of interest are
behavioural and/or psychological, and
because CR does not target a biological or
cognitive process per se, biomarkers
(including cognitive performance), often
regarded as key endpoints in other
intervention approaches, are seen as less
relevant in studies of CR efficacy.
One solution to overcoming difficulties
with outcome measurement in the
context of individualised interventions
such as CR is the use of measures of goal
attainment. Goal attainment measures
such as the Goal Attainment Scaling
(Kiresuk et al 1968; Malec 1999), the
Canadian Occupational Performance
Measure (Law et al 2005), or the Bangor
Goal Setting Interview (Clare et al 2012b)
allow for progress in relation to
individualised goals to be converted into
standardised scores, which is an
important methodological feature in
group studies.
Such an approach, of course, is not
without its limitations in the context of
trials in which participants and
caregivers are not blinded to the
intervention they receive, and
researchers must continue exploring
ways to improve outcomes measurement
in studies of CR.
Finally, for CR and any other
intervention approach based on
principles of enablement to be
successfully integrated into the care of
people with dementia, more work needs
to be done to understand how to shift
views, perspectives and practices to be
more aligned with an enablement
framework.
Shifting attitudes and beliefs
Changing longstanding attitudes held by
some members of the healthcare
community, and indeed often by people
with dementia and their families – that
often focus primarily on the need for a
‘cure’ rather than on the possibility of
living better with dementia – is possibly
among the most significant challenges in
the field.
Shifting attitudes and beliefs is often a
slow process. A coordinated approach in
which scientists work collaboratively
with advocacy groups, government,
industry and even the media is required
to bring about wide-scale changes in
world-views.
Such changes are critical if enablement
approaches such as cognitive
rehabilitation are to be truly integrated
into the way we work with people with
dementia and their families, and with
older adults more broadly.
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DCRC SPEC I AL I SSUE : THE B I G P I CTURE I N DEMENT I A RESEARCH