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What do you do that gives your brain a workout? I find that activities such as travel, attending a course or workshop or conference, meeting new people, going to a festival or parade, organizing a big event or performing on stage all work out my brain. What these activities have in common is that they require me to process and react to a lot of new information.
People with dementia often find it difficult to cope with a lot of new information. Most people with dementia would find it challenging, though not necessarily impossible, to travel, learn something new, meet many new people or go to a crowded event. This is why they are advised to keep to a routine and avoid potentially overstimulating experiences. However, there is a downside to sticking to a routine. Routines tend to reduce the opportunities to give their brain a workout. A stimulating routine is what we should aspire to create for people with dementia.
This chapter gives ideas about how to develop and deliver tailored cognitively stimulating activities for people with dementia. The ‘dose’ that has been shown to be beneficial in improving cognitive function for people with dementia is two 45-minute group sessions per week. Increasing the amount of cognitive activity may increase the positive impact, however this has not been shown. To achieve cognitive benefits, try to provide a minimum of 90 minutes of cognitively stimulating activity every week, spread out across as many sessions as needed. Conduct a range of different activities that exercise different aspects of thinking and memory. Most of the ideas discussed in the other chapters can be cognitively stimulating.
An engaging philosophy of care is cognitively stimulating. We encourage the person with dementia to think, experience and interact with different things every day. Choose issues or topics that the person finds interesting. Alternatively, use the social aspect of the activity to make the discussion meaningful. In general, ask for opinions rather than facts. When the person is asked to solve a problem, celebrate their achievements—do not point out their errors. If the person is unable to solve a problem by themselves, work together with them towards success.
Researchers have tried three mental activity-based approaches to improve the cognitive abilities of people with dementia.
There is good consistent evidence for the benefits for cognition of cognitive stimulation therapy, which focuses on encouraging and facilitating fun and stimulating discussions. Cognitive stimulation therapy has the same benefits on maintaining cognitive functions as currently available drugs (e.g. cholinesterase inhibitors) for Alzheimer’s disease. This is typically delivered in a small group of four to five people with mild to moderate dementia for 45 minutes, twice a week for fourteen weeks. Sessions have a set structure typically including introductions, discussion about day, season and current affairs, a song, a ball game, the main discussion topic for the day, summary and farewell. Examples of discussion topics may be famous faces, using money, word games and personal histories.
The benefits of cognitive stimulation therapy have been shown to be maintained for up to six months and it would be reasonable to assume that ongoing cognitive stimulation would provide ongoing benefit in slowing decline. The groups are led by a health professional, and detailed manuals are available for purchase (see ‘Further resources’). Sessions aim to actively stimulate and engage people with dementia while providing an optimal learning environment and the social benefits of a group.
Cognitive training, or brain training, focuses on exercising specific mental abilities, such as short-term memory, attention or problem solving. The research has had mixed findings and overall brain training, either computerized or using pencil and paper, doesn’t seem to improve specific or general mental abilities. This may be because brain-training exercises train a specific skill, such as remembering a list of words, and this skill doesn’t generalize to other types of memory, such as remembering someone’s name or remembering to watch a certain television show at a certain time. This is similar to how bicep curls don’t improve leg strength or whole body strength.
Cognitive rehabilitation focuses on identifying and addressing individual cognitive difficulties. For instance, the person with dementia may want to learn the names of people in a group they attend, or to learn how to use a mobile phone. The therapist develops strategies to address their aims, using specific techniques for learning new information. The results from one study of cognitive rehabilitation have been promising.
Below are ideas for different types of cognitively stimulating activities for people with dementia. These do not have to be tightly tailored to the life history of a person with dementia. However, I would avoid topics they did not enjoy or were uninterested in earlier in life.
Treat all these ideas as springboards for conversation and discussion. The person with dementia should be stimulated to react to the topic or activity, to use their knowledge on the topic to generate an opinion and response, and communicate their thoughts or act on their response. While these activities have been described as being for one person, many would work very well in small groups. Treat this list as inspiration rather than prescription and create your own activities according to your situation.
This activity is more appropriate for people with mild to moderate dementia. Discussions should not just tap the person’s knowledge about the topic but also their opinions and ideas. Activities may require the person to solve a problem, for instance using a map to plan a long-distance trip. Or the person might have to arrange three historical events in chronological order. Or they may have to answer true or false to a number of scientific ‘facts’. You could think of these activities as similar to exercises that school students are given to encourage them to engage with a topic such as science, history or geography. However, where school students have to acquire knowledge as part of the task, the people with dementia use the knowledge they already have in the activity. Here are topics around which you can create discussions:
People with dementia often surprise us with what they create when given the opportunity. Perhaps it is because they are less inhibited due to changes in their frontal lobes. Perhaps it is because they live in the moment much more than those of us with better memories. Perhaps it is because they have fewer opportunities to express themselves. Whatever the reason, people with dementia have been shown to flourish when being artistic.
How do you get people with dementia to be creative? Give them some materials and some inspiration. Artists tell me that having a theme or focus stimulates rather than constrains creativity. A standard cognitive test requires a person with dementia to ‘Write a sentence about anything you like’. We find that people with dementia find it difficult to think of a sentence to write. However if we give that same person a photograph, and say ‘Tell me a story about the person in this photograph’ we find that they can make up many sentences worth of story. So, when presenting a creative activity, give the person a medium (e.g. storytelling or painting) and a theme to work on. Here are some further ideas:
Sensory stimulation can be very pleasurable, such as looking at a beautiful view. Discussion of sensory experiences in the moment can also stimulate other parts of the brain. Here are some ideas:
Here are some ideas for made-up games—you can also come up with your own!
Do something that connects the person with the outside world. Being outdoors releases different chemicals in the brain than when indoors, and can improve stress levels and increase creativity. For example:
This activity works better with people with some verbal communication ability, as it relies on the person with dementia giving their opinion on a selected topic; it could, however, be adapted using pictures or objects for a person with dementia who doesn’t speak well. Topics could be:
Bernie has created some activities that he thinks may be cognitively stimulating for Joy, based on her interest in fashion and travel.
The conversation continued for a few minutes more, with Joy providing commentary on the outfits she liked. While this activity was of interest to Joy, it didn’t sustain her attention for long and wasn’t very cognitively difficult for her. Perhaps it lacked meaning or purpose for Joy as well. Bernie then developed a fashion-related sorting activity for Joy and tried it a few days later.
The activity continued with Joy sorting the clothing pictures into piles. Bernie used the same question each time in this activity, and after a few pictures Joy didn’t require the question. He doesn’t correct Joy when she makes a mistake. There were opportunities for the conversation to take a different direction; for instance, after Joy said that she wouldn’t wear an outfit Bernie could have asked what she didn’t like about it or why she wouldn’t wear it. Bernie could have experimented with how much prompting or gesturing he needed to give Joy, or whether she could do the activity with minimal assistance. Also, the next time they do the activity Joy may need even less prompting (even if she doesn’t remember ever doing the activity before).
A few days later, Bernie tries an even more challenging activity with Joy—storytelling.
The conversation continues until the postcard is full, then they write a postcard from France.
Develop a mentally stimulating routine. Take and make opportunities to do things that challenge your brain every day. Doing a cognitively stimulating activity doesn’t mean just sitting at a desk and doing crosswords or brain-training exercises. It means doing activities that make you think, such as scrutinizing the world around you (e.g. bird watching), learning new things (e.g. using new technology), thinking about things in different ways (e.g. having a philosophical discussion), solving problems (e.g. checking the monthly budget) and working things out (e.g. planning a holiday). You may do this with someone else or by yourself. Try to exercise all the functions of the brain discussed in Chapter 2.
You might want to avoid doing mentally challenging activities because it reminds you of the decline in your mental faculties. You might also want to avoid doing some of these in public because you want to keep your self-respect. In terms of protecting your self-confidence, avoidance makes sense. However, if you avoid mentally challenging activities you probably exercise your brain less and also lose opportunities to socialize and do some things that you may enjoy.
You could try to accept that dementia is a condition that results in cognitive deterioration but that this isn’t your fault and doesn’t reflect your self-worth, in the same way that cancer is a condition that results in tumours but this doesn’t reflect on the worth of the person with cancer. Knowing that it isn’t your fault doesn’t mean that you won’t feel that it is your fault, or that you have less ability than before. Living a full life and enjoying the things you can do may be how you can feel best about yourself.
Plan your day so that you’re doing cognitively stimulating activities at a time when you feel your best. For instance, plan to do these activities mid-morning if that is when you’re freshest. Or if you have an evening engagement, plan a quiet day so that you have more mental energy at night.
Keep on doing things that challenge you mentally! Even if it is difficult, and even if on bad days you don’t perform as you would like. Set yourself an achievable goal and work towards that, or do something you have been putting off or avoiding. If you stop challenging yourself, you stop exercising your brain.
You are probably finding that it takes much more effort to learn new things and you have to actively ‘process’ the information rather than just learn it with minimal effort. There are specific techniques used in cognitive rehabilitation that may be helpful for you—some are given below.
Motor and procedural memories are encoded and stored separately to memories for facts and events. Take tying a shoe lace. You know the movements of how to tie a shoe lace. However, if I asked you to write down how to tie a shoe lace you would have to think about it, because the process is stored in motor memory, not in words. The memory systems for procedures tend to be less affected by dementia, particularly Alzheimer’s disease, than memory systems for facts. So, when learning a procedure, don’t learn it as a written list of steps—rather, train the motor movements. Practise the sequence even though you can easily complete the individual steps. If someone is telling you how to turn on the new television, don’t just listen to the instructions. Get the remote control and press the buttons as they speak. Then repeat the procedure a few times to make sure you have thoroughly learnt it.
The more you think about and process information when trying to learn it, the more likely you are to remember it. One way of adding processing is to think about the information in a different way. So, if you’re trying to learn someone’s name, instead of just repeating the name ‘Adam, Adam, Adam’ to yourself, you think ‘Adam, he was the first man in the creation story, he was tempted by the apple.’ Then you picture the person whose name is Adam, eating an apple.
Another technique for learning new information is to practise recalling the information from storage within a short time of learning it, when you’re more likely to remember it. So, within an hour of learning the person’s name you might try to remember the name again, and then practise remembering it again within 2 hours, then 5 hours, then 10 hours and then 24 hours, extending the time between your practices. This technique is called spaced retrieval, because you space out the delay between retrieving the memory each time. Every time you recall the person’s name you’re actually writing it more firmly into your memory, and practising getting it out of your memory.
The method of loci is a technique for remembering lists of things in a certain order. The technique involves choosing a physical route that you know well, such as the walk from your bedroom to the lounge room, or the walk from your house to church. As you walk the route in your mind, you associate each landmark (the bed, the cupboard, the bedroom door, etc.) with an item on your list. You mentally practise walking the route until you’ve learnt the associations. When you need to remember the list, you can then walk the route in your mind and use each landmark as a prompt.