사업단 연계 및 체계

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1 Rehabilitative Intervention of Cognitive Disorder and Dementia Yun-Hee Kim, MD, PhD Dept. of Physical Medicine & Rehabilitation, Division for Neurorehabilitation Stroke and Cerebrovascular Center, Samsung Medical Center Sungkyunkwan University School of Medicine

2 Cognitive Rehabilitation A systematic, functionally oriented service of therapeutic activities that is based on assessment and understanding of the patient s brainbehavioral (cognitive) deficit. Restoration of function Compensation & substitution

3 Clinical Areas of Implication Stroke / Post-stroke Cognitive Impairment Vascular Dementia / Vascular Cognitive Impairment Traumatic Brain Injury Alzheimer s Dementia / Mild Cognitive Impairment Degenerative Brain Disease with Dementia

4 Dementia Dementia is defined as a primary decline of intellect and/or comportment due to a structural and chemical brain disease to the point that customary activity of daily living (ADLs) become compromised. Korean society is rapidly becoming an aging society where average age increases, and dementia is becoming more prevalent. Proper management and rehabilitation therapy is highly recommended for patients with dementia, in a way that it prevents the functional deterioration as well as reduction of national welfare burden.

5 Prevalence of Dementia VD 24% Other Dementia 5% AD 71% 2008 Ministry of Health and Welfare

6 Rehabilitative Intervention for Dementia Problems Cognitive decline Progressive memory disorder Attention / executive / visuospatial / language dysfunction ADL dependency Instrumental ADL, basic ADL Physical problems Subtle involvement of motor function Balance and coordination disorder Behavioral problems Agitation, insomnia, paranoid behavior Interventions Cognitive Rehabilitation Exercise Therapy Pharmacologic management

7 I. Cognitive Rehabilitation for Dementia Why? How? When?

8 Background of Cognitive Rehabilitation in Elderly and Patients with Dementia Evidence of plasticity in aging brain Existence of training-induced plasticity of cognitive network

different functional brain network to compensate for reductions of

9 Plasticity of Aging Brain Older brain Life-long capacity for plasticity and adaptive reorganization Older individuals utilize different functional brain network to compensate for reductions of efficiency in task related brain areas. Cabeza et al, Cerebral Cortex, 2004

10 Aging Gracefully Source memory task: Performance grouping Brain activity tends to be less lateralized in older adults than younger adults. Compensation hypothesis: Bihemispheric involvement could help counteract age-related neurocognitive decline. High-performing older adults counteracted age-related neural decline through a plastic reorganization of neurocognitive network. Cabeza, Neuroimage, 2002

11 Training-related Cognitive Plasticity of Attention Network Kim et al, Neurorehabil Neural Repair, 2008

12 Types of Cognitive Interventions Cognitive stimulation Group activities designed to increase cognitive and social functioning in a non-specific manner Cognitive training Structured practice on standard tasks aimed at improving specific cognitive functions, such as memory, attention, executive function etc. Cognitive rehabilitation Individually tailored programs to identify personally relevant goals and devices and implement strategies focused on specific activities of daily living *often used interchangeably

13 Methods of Memory Retraining Optimization of residual function Training of mnemonic strategies: Strategy training Semantic elaboration Visual imagery training The method of loci (mnemonics) Training recollective processes: Restitution training Exercise and drills, practice, experience, time and effort ** Strategy training >> Restitution training Substitution of intact function Use of implicit memory system Vanishing cues/spaced retrieval/errorless learning Compensation for lost function External memory aids Cicerone, Arch Physical Med Rehabil, 2005, Glisky, 2008

Effect of Cognitive Training in AD The Cochrane Library, 2008 Early stage AD & VD 9 RCTs for cognitive training Memory and other cognitive function No specific positive

15 Effect of Cognitive Training in AD The Cochrane Library, 2008 Early stage AD & VD 9 RCTs for cognitive training Memory and other cognitive function No specific positive effect No specific negative effect Evidence remains limited Lack of standardized outcome measure No conclusion for cognitive rehabilitation Well designed study is recommended

16 Effect of Cognitive Rehabilitation in AD

17 CONSORT Chart

18 Cognitive Rehabilitation Protocol CR involved 8 weekly 1-hour individual sessions The main focus: individualized intervention addressing personally meaningful goals which were supported by practical aids and strategies Practice in maintaining attention and concentration Techniques for stress management Participants were encouraged to practice strategies between sessions Carers were invited to join the last 15 minutes of each session to support between-session implementation

19 CR produced significant improvement in ratings of goal performance and satisfaction which support the clinical efficacy of CR in early stage AD Intervention-related BOLD signal change (Increased activation) in fmri Rt. fusiform face area/parahippocampal cortex Rt. temporal parietal junction/medial prefrontal cortex

21 Mild Cognitive Impairment (MCI) Subclinical cognitive deficit Not normal but not meet criteria for dementia syndrome DSM IV, ICD 10, NINDS-AIREN Progress to probable AD 10-15%/yr, 25-30%/3yrs. Subtypes of amnestic MCI High risk to progress to AD

22 Cognitive Intervention for MCI Am J Geriatr Psychiatry, 2010

23 Effect of Cognitive Intervention in MCI Fifteen studies analyzed: 5 were RCTs, 8 were quasiexperimental designs, and 2 were single-case investigations Diverse methods were used: cognitive training, cognitive stimulation, cognitive rehabilitation, computer-assisted cognitive intervention program Significant improvements on 44% of objective measures of memory at the end of therapy Significant improvements on 49% of subjective measures of memory, quality of life, or mood Jean et al, 2010, Paucounau et al, 2010

24 Conventional vs. Computer Both traditional and computer-based cognitive intervention programs seem to be effective The computer-based training present more advantages: Individualize the program tailored to the patient s neuropsychological pattern and needs Immediate objective comparison by providing instant value-free feedback. A possibility of a widescale dissemination.

25 160 community-dwelling men and women aged 65 years of age or over with MCI Non-specific education vs. cognitive activity Ten 90-minute sessions, twice per week Memory, attention, executive functions, mood and QOL 12, 52 and 104 weeks after the baseline assessment Implications for the development of evidence-based preventive strategies to reduce the rate of cognitive decline amongst older people at risk of dementia Trial registration: ACTRN

Cognitive Intervention in Elderly Am J Geriatr Psychiatry 2009 Meta analysis of 54 studies Cognitive exercise training in healthy older individuals produces strong and persistent protective effects

26 Cognitive Intervention in Elderly Am J Geriatr Psychiatry 2009 Meta analysis of 54 studies Cognitive exercise training in healthy older individuals produces strong and persistent protective effects on longitudinal neuropsychological performance. A strong effect size was observed for cognitive exercise interventions compared with wait-and-see control conditions. Transfer of effects to dementia-relevant domains such as general cognition and daily functioning has also been reported in some studies.

27 Timing of Intervention

28 II. Exercise Therapy for Dementia Effects in healthy and dementia

29 Effect of Exercise in Elderly Positive effect of exercise in older adults was well established Aerobic exercise intervention increased cardiopulmonary fitness coincided with improved cognitive capacity Large effect on motor function and auditory attention, moderate effect on cognitive speed and visual attention Aerobic fitness training have an association with reduced brain tissue loss in aging human

30 Regulation of Brain Function by Exercise Sutoo and Akiyama, Neurobiology of Desease, 2003

environmental stimulation Disuse atrophy

31 Physical Problems in Dementia Physical problems commonly accompanied with dementia Limited mobility Long-term institutionalization Lack of proper environmental stimulation Disuse atrophy and deconditioning Balance and coordination disturbance Fall and fracture

33 Exercise Protocol for Dementia Orientation to the rationale for training Establishes mutually agreed-upon goals Exercise training to maintain strength and mobility Gentle stretching, strengthening, balance, endurance training Focused on easy, availability, and pleasantness Systematic ways to increase pleasant events Select activities that will enjoy, eg., dancing steps Caregiver education Effective communication, Problem-solving training

34 신체기능증진을위한운동 관절가동운동 (Range of motion exercise) 신전운동 (Stretching exercise) 유산소운동 (Aerobic exercise) 걷기 (Walking) 달리기 (Jogging) 수영 (Swimming) 자전거타기 (Bicycling) 체조, 춤 (Dancing) 과제지향운동 (Task-oriented training) 60-70% of age-predicted maximum heart rate min/session 3-5 times/week Daily flexibility training

35 Cardiac Precautions during Exercise Activity should be terminated if any of the following develops: New onset cardiopulmonary symptoms Heart rate decreases >20% of baseline Systolic BP increases to 240 mm Hg Systolic BP decreases >30 mm Hg of baseline or to <90 mm Hg Diastolic BP increases to 120 mm Hg

37 Effect of Exercise in Dementia Does Exercise improve cognitive function as well as physical function of AD patients?

2,020 subjects, 30 trials, Meta-analysis Arch Phys Med Rehabil, 2004 Exercise was associated with statistically significant positive treatment effects in older patients with dementia and cognitive

38 2,020 subjects, 30 trials, Meta-analysis Arch Phys Med Rehabil, 2004 Exercise was associated with statistically significant positive treatment effects in older patients with dementia and cognitive impairments. A medium to large treatment effect for health-related physical fitness components An overall medium treatment effect for combined physical, cognitive, functional, and behavioral outcomes

Clin J Sport Med, 2008 23 studies included 15 in cognitively healthy subjects Statistically beneficial intervention effect in 5 studies Information processing, executive function, memory Aerobic Ex.

39 Clin J Sport Med, studies included 15 in cognitively healthy subjects Statistically beneficial intervention effect in 5 studies Information processing, executive function, memory Aerobic Ex., strengthening Ex., str. +balance Ex., all-round Ex. 8 in subjects with cognitive decline Statistically beneficial intervention effect in 5 studies General cognition, executive function, memory Aerobic Ex., Str. + flexibility/balance tr. Diversity of exercise program: No conclusion about the preferred type of exercise

40 Steps in Cognitive Rehabilitation Early diagnosis of cognitive disorder Precise evaluation of all cognitive domains Define strengths & weaknesses of patient Goal setting with patients and family Focused treatment Outcome assessment Reestablishment of goal if needed

41 Elements for Effective Cognitive Therapy Working team Common philosophy of treatment Identifiable problems evaluated by team Realistic goal setting Order of treatment Team communication Evidence-based treatments

42 Considerations for Goal Setting Characteristics of underlying disease Normal ageing Stationary vs. progressive disease Severity of involvement Environmental factors Therapeutic environment: Personnel, equipment Home environment What can be achieved during the certain time period

43 성공적인인지재활프로그램의요건 평가 (Assessment) 목표설정 (Goal setting) 실행계획 (Exacution) 인지재활팀 (Cognitive Rehabilitation team) 환경요인 (Environmental factors) 신체적활동 (Physical activities)

44 평가 (Assessment) 대상환자의질병의특성을충분히파악하였는가? 각인지기능의영역별포괄적평가를실시하였는가? 환자가가지고있는강점과약점을충분히분석하였는가? 재활가능영역과예상기간에대한예측이가능한가? 기능과환경에대한평가가되어있는가? Basic ADL Instrumental ADL Vocational competency Environmental assessment ICF

45 The ICF and Dementia ICF (International classification of functioning, disability, and health): A framework for describing and classifying an individuals health and health-related states. Level of Impairment Functioning and Disability Functioning: Body function, structure, activity, participation Disability: activity limitation/participation restriction Contextual Factors: personal and environmental factors Personal factor: gender, age, personal history, habit Environmental factor: physical, social, attitudinal characteristics of environment

48 Personal & Environmental Factors Physical co-morbidity Depression Anxiety Housing environment Family support

49 목표설정 (Goal Setting) 치료전목표설정이되어있는가? Short-term goal Long-term goal 목표는현실적이고달성가능한가? 환자와가족 ( 보호자 ) 이목표설정에참여하였는가? 목표는충분히구체적인가? 목표는충분히도전적인가?

50 실행계획 (Execution and Planning) 목표달성을위한세부적인치료계획이준비되어있는가? 치료사는이러한문제를해결할수있도록충분히교육되어있는가? Stereotypic 한치료를반복하지는않는가? 환자의흥미를고려하여유연성있게치료내용을구성하는가? 기본적, 도구적일상생활훈련을포함하고있는가? 가정에서반복할수있도록지침이주어지는가?

51 인지재활팀 인지재활팀은필요한각과전문의사, 인지재활치료사, 임상심리사, 간호사, 사회복지사등필요한인력을갖추고있는가? 환자의평가결과를공유하고목표설정을위한팀회의를하는가? (Team conference) 팀멤버들간에충분한의견교환이이루어지는가? 재평가회의를하는가? 목표가적절치않다고판단되었을때목표의재설정을실시하는가?

52 환경요인 치료시간에배운내용을가정에서반복할수있는환경이조성되어있는가? 낙상과같은합병증을예방할수있도록환경이개선되어있는가?

53 신체활동 신체적훈련을병행하도록운동프로그램을실시하는가? 인지담당치료사는운동시의주의점을충분히숙지하고있는가? 운동프로그램은환자의흥미를유발하는데충분한가?

54 인지재활프로그램의실패요인 환자의동기부족 비현실적인목표설정 : 환자, 가족, 치료자 치료자와환자간의목표의차이 치료환경조성실패 : 소음, 주의산만 성취감부족및좌절 : slow progress 치료의장기화 : 단기목표부재 치료자와환자, 가족의상호협조부족

55 인지재활치료시흔한문제점 포괄적인인지재활팀의부재 훈련된의사와치료자부족 적절한평가와문제점파악능력 뇌질환과병소의특성에근거한예후예측능력 Goal setting 다양한치료적개입방법및유연한적용 환자와의 interaction을통한동기와흥미유발 가정에서의 carry-over를위한협조와시스템부족 Co-morbidity 를고려한 physical exercise program

56 Conclusions I Cognitive and neural plasticity are present across the adult life span, although there are age-related reductions in the potential for improvement Early cognitive intervention is effective in preventing cognitive decline and development of dementia in elderly people and MCI patients. Individualized cognitive rehabilitation and cognitive training using traditional or computer-assisted methods can be applied for enhancing cognitive function of MCI and early dementia

57 Conclusions II Physical exercise with pleasant events showed improvement in both physical and cognitive function of dementia patients, therefore, it should be emphasized for cognitive intervention of dementia Larger studies using standard outcome measure are required to define the specific methods of cognitive and exercise interventions most effective for patients with dementia.

58 Case 1: 44/F, ICH due to AVM 2009/4/2 2009/5/4 2009/4/23

59 2009/6/10

61 Copy Line bisection task Immediate

62 Problem List Problem lists Deficit in attention and working memory Deficit in processing of visual stimuli Lt. side neglect Lt. visual field deficit Depression and anxiety Lack of insight to her own disability Difficulty in coping with outpatient care Strengths Highly intellectual Strong family support Good verbal skills Strong desire for returning to previous job

63 Goal Setting Short-term goal Improving attentional processing to visual materials Improving Lt. side awareness Build up insight on her own problem Optimizing mood status Activities Saccadic eye movement training using computer program Attention training using ComCog program Logical analysis of activities with patient Regular physical exercise Home program Paper-pencil task: 점선잇기, 미로찾기, 틀린그림찾기 Activity diary: 가정에서당하는어려움을관찰및기술

64 Long-term goal Improving memory function Improving complex visuomotor coordination Compensation technique to residual disability Job competency: Cognitively and psychologically Activities Strategy training Method of loci Verbal strategy Visuoconstruction training using computer program and block tasks Home program IADL training: 다리미사용, 도로건너기, 시장보기 Prevocational activity: 문서해석과관리

65 2009/10/9

66 Line bisection task Immediate Copy Delayed

67 Neuroplasticity & Brain Mapping Research Laboratory

Dementia2

Dementia2 Today s Topics Memory Impairment & Dementia Age Associated Memory Impairment Dementia Definition of dementia Depression Schizophrenia Mental retardation Delirium : Not final diagnosis term, but symptomatologic