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COGNITIVE REHABILITATION USING GRADIOR WITH PATIENTS DIAGNOSEDAS HAVING ALZHEIMER TYPE DEMENTIA (MILD)

A PRACTICAL CASE STUDY

What follows is a description of the case of a patient diagnosed with AD (mild) included in acomputerized rehabilitation program (GRADIOR) during a one year period.

1.- CURRENT ILLNESS AND REASONS FOR SEEKING COUNSEL:

Approximately one year ago seventy-seven year old A.A.D. arrived at the consultancyseeking help with memory and concentration difficulties (progresive memory loss), which to a certainextent, hindered the development of some of the patient’s everyday activities. One of these acivitiesin which the patient observed a less than normal performance was in his weekend job where hewould receive telephone calls and take currency changing orders solicited by various city firms. Heobserved that the order forms would become increasingly full of ink blots and he needed to repeatthe operation many times to take the “message” correctly. At the same time, he began to suffer slightdizziness at specific moments, on going up the stairs for instance. Relatives began to note slightabsent-mindedness which without interfering too much in everyday life were significant. Likewise, atthe moment of the first session, the presence of subdepressive symptoms were observedfundamentally due to the patient’s subjective feeling of being incapacitated. This had been going onfor roughly a year during which the patient had been progressively exhibiting symptoms, firstly withsensations of being incapable and forgetfulness and later with a more notorious functional memoryloss.

2.- DIAGNOSIS PROCEDURE:

After exposing the above complaints A.A.D. went through the following phases.

PHASE 1 Diagnosis:

In this Phase an exhaustive analysis of the presenting symptomatology was carriedout at both an organic and neuropsychological level . The following tests were made:

Medical Explorations:

* Chemical Analysis: Routine blood and urine tests were found to benormal.* E.E.G. and C.A.T. scans also normal.

Neuropsychological Explorations: A series of tests aimed at detecting thepresence of everyday afect and cognitive deterioration were carried out on thepatient as well as tests to measure afect development among the patient’s relatives.This first neuropsychological exploration provided the baseline assessment pre-cognitive rehabilitation. The tests used in this initial evaluation were: Mini CognitiveExamination (Lobo et al, 1979 y 1980), spanish version of MMSE (Folstein et al,

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1975); Test ADAS (Rosen et al., 1984); Clock Drawing Test (Freeman et al,1994); Lawton Scale (Lawton y Brody, 1972); Barthel Index (Mahoney y Barthel,1965); IQCODE (Jorm and Jacomb, 1989); Nottingham Quality of life scale (Huntand Ewen, 1980) Global Clinical Impression scale, G.C.I. (Guy, 1976).

The results obtained in the baseline evaluation were: Mild cognitivedeterioration (mnesic and attentional difficulties), evidence of mild dementia ADtype, and independant daily living. In the table below, the scores obtained in each ofthe tests are exposed.

BASELINE EVALUATIONMEC ADAS CDT LAWT BARTH G.C.I. S. CUID C.V.

N.C C TOTAL EV FAM24 14 9 23 16 5 95 2 2 4 8

Conclusion: The CIE-10 manual was applied for diagnosis. Alzheimer’s Diseasewas diagnosed with no associated behavioural disorders.

Family History: No family history of AD was found

3.-APPLICATION OF THE GRADIOR REHABILITATION PROGRAM:

PHASE 2 Rehabilitatión:

The rehabilitation involved the inclusion of a computerized neuropsycholgical rehabilitationprogram (GRADIOR) (Franco y cols., 2000). A general objective of neurocognitive stimulation andtraining was established. In order to meet this aim, the rehabilitation was to consist of concentratingand acting on neuropsychological aspects that the patient still conserved or on those that were leastdeteriorated so as to begin compensating the patient’s deficits from there. In his way, therehabilitation is not focussed exclusively on deficiencies but is established in accordance with theabilities which the patient already posseses intervening in the execution process working from acompensation perspective instead of a loss perspective.

The GRADIOR program was developed under the following premises (Franco ycols.,2000):

- It is a totally personalized program: i.e. the incoprporated tasks are in consonancewith the kind of deficits detected, these mainly being from: attention, memory andinformation processing.

- It has an ecopsychological focus which bears in mind environmental factores whenit comes to carrying out intervention stratagies

- Rehabilitation is developed under a global planning and integral treatment stratageytaking into account other factors such as emotional ones.

Bearing all this in mind, this patients rehabilitation program was established using theGRADIOR program in twice weekly 25 minute sessions (Mon. and Wed.)

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4.- EVOLUTION AND FOLLOW UP:

PHASE 3 Rehabilitation Follow up (progress)

During the rehabilitation using the program GRADIOR periodic assessments were made inorder to evaluate progress. Asessments of this kind were made at 3, 6, 9, and 12 months aftercommencing rehabilitation. The following table displays the results obtained throughout this process:

3 MONTHSMEC G.C.I. C.D.T. S. CUID

EV. FAM

34 2 2 17 06 MONTHS

MEC ADAS C.D.T. LAWT BARTH G.C.I. S. CUID C.V.N.C C TOTAL EV FAM

29 16 2 18 16 5 95 2 2 0 59 MONTHS

MEC G.C.I. C.D.T. S. CUIDEV. FAM

33 2 2 18 0ASSESSMENT AFTER 12 MONTHS

MEC ADAS C.D.T. LAWT BARTH G.C.I. S. CUID C.V.N.C C TOTAL EV FAM

33 12 4 16 18 5 95 2 2 0 8

As you can see, advances were made in the improvement of cognitive aspects. Thisimprovement had repercussions in the patient's everyday life as well as in the realization of his job(taking orders by phone). This was evident in the fact that the order forms no longer had as manyink blots or scribbbles, neither did he have to repeat the order so many times in order to get it right.Likewise, his mood also got better, his self-esteem being reinforced on seeing the various successeswhich he had acheived not only in his cognitive rehabilitation but also (and more importantly) in hiseveryday life.

5.- CONCLUSION:

This case shows the benefits that can be reaped from cognitive rehabilitation with peoplewho present memory problems, firstly with regard to cognitive processing and secondly with regardto their everyday life development (Franco y cols., 1998).

Taking advantage of the resources that information technology can provide when it comes topresenting cerebral training tasks (new and striking stimuli, with the capacity for movement,variability of the type of stimulus...), the GRADIOR program (as an interactive program between apatient and a computer with a touch sensitive monitor), a new tool which appears at first glance tobe something which could never be useful to people with cognitive difficulties, can be seen as apotential reinforcer in rehabilitation. Likewise, given such a new presentation as far as the elderly areconcerned, this kind of program foments greater motivation when it comes to discovering "What elsewill it show me", and with that, continuity, an indispensable aspect in good rehabilitatory practice, isaumented.

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6.- BIBLIOGRAPHY

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FRANCO, M.A.; ORIHUELA, T.; BUENO, Y.; CID, T. Programa Gradior. Carácterísticasgenerales. Zamora, Edintras, 2000.

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LAWTON, M.P., BRODY, E.M. Assessment of older people. En: Kent, D.. Kastenbaum, R.,Sherwood, S. (Eds.). Research , planning and action for elderly. Behavioral Publications, NewYork 1972; 122-143.

LOBO, A.; EZQUERRA, J.; GOMEZ-BURGADA, F. Y COLS. El Mini-Examen Cognoscitivo(un test sencillo, práctico, para detectar alteraciones intelectuales en pacientes médicos). Actas luso-españolas de Neurología, Psiquiatría y Ciencias afines. 1979; 3: 189-202.

LOBO, A.; ESCOLAR, V.; ESQUERRA, J.; SEVA, A. Mini-Examen Cognoscitivo: un testsencillo y práctico para detectar alteraciones intelectivas en pacientes psiquiátricos. Rev. Psiq.Psicol. Med 1980; 5: 39-57.

LOBO, A.; VENTURA, T.; MARCO, C. Psychiatric morbidity among residents in a home for theelderly in Spain: prevalence of disorder and validity of screening. Int. J. Geriatr. Psychiatr. 1990; 5:83-91.

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