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COGNITIVE REHABILITATION USING GRADIOR WITH PATIENTS DIAGNOSED AS 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 a computerized 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 consultancy seeking help with memory and concentration difficulties (progresive memory loss), which to a certain extent, hindered the development of some of the patient’s everyday activities. One of these acivities in which the patient observed a less than normal performance was in his weekend job where he would receive telephone calls and take currency changing orders solicited by various city firms. He observed that the order forms would become increasingly full of ink blots and he needed to repeat the operation many times to take the “message” correctly. At the same time, he began to suffer slight dizziness at specific moments, on going up the stairs for instance. Relatives began to note slight absent-mindedness which without interfering too much in everyday life were significant. Likewise, at the moment of the first session, the presence of subdepressive symptoms were observed fundamentally due to the patient’s subjective feeling of being incapacitated. This had been going on for roughly a year during which the patient had been progressively exhibiting symptoms, firstly with sensations of being incapable and forgetfulness and later with a more notorious functional memory loss. 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 carried out at both an organic and neuropsychological level . The following tests were made: Medical Explorations: * Chemical Analysis: Routine blood and urine tests were found to be normal. * E.E.G. and C.A.T. scans also normal. Neuropsychological Explorations: A series of tests aimed at detecting the presence of everyday afect and cognitive deterioration were carried out on the patient as well as tests to measure afect development among the patient’s relatives. This first neuropsychological exploration provided the baseline assessment precognitive rehabilitation. The tests used in this initial evaluation were: Mini Cognitive Examination (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 (Hunt and Ewen, 1980) Global Clinical Impression scale, G.C.I. (Guy, 1976). The results obtained in the baseline evaluation were: Mild cognitive deterioration (mnesic and attentional difficulties), evidence of mild dementia AD type, and independant daily living. In the table below, the scores obtained in each of the tests are exposed. BASELINE EVALUATION MEC

24

N.C

ADAS TOTAL C

14

9

23

CDT

LAWT

BARTH EV

16

5

95

2

G.C.I. FAM

2

S. CUID

C.V.

4

8

Conclusion: The CIE-10 manual was applied for diagnosis. Alzheimer’s Disease was 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 rehabilitation program (GRADIOR) (Franco y cols., 2000). A general objective of neurocognitive stimulation and training was established. In order to meet this aim, the rehabilitation was to consist of concentrating and acting on neuropsychological aspects that the patient still conserved or on those that were least deteriorated so as to begin compensating the patient’s deficits from there. In his way, the rehabilitation is not focussed exclusively on deficiencies but is established in accordance with the abilities which the patient already posseses intervening in the execution process working from a compensation perspective instead of a loss perspective. The GRADIOR program was developed under cols.,2000):

the following premises (Franco y

- It is a totally personalized program: i.e. the incoprporated tasks are in consonance with the kind of deficits detected, these mainly being from: attention, memory and information processing. - It has an ecopsychological focus which bears in mind environmental factores when it comes to carrying out intervention stratagies - Rehabilitation is developed under a global planning and integral treatment stratagey taking into account other factors such as emotional ones. Bearing all this in mind, this patients rehabilitation program was established using the GRADIOR 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 in order to evaluate progress. Asessments of this kind were made at 3, 6, 9, and 12 months after commencing rehabilitation. The following table displays the results obtained throughout this process: 3 MONTHS MEC EV.

34

G.C.I. FAM

2

2

C.D.T.

S. CUID

17

0

6 MONTHS MEC

29

N.C

ADAS TOTAL C

16

2

18 9 MONTHS

C.D.T.

16

EV.

33

ADAS TOTAL C

12

4

16

5

G.C.I. FAM

33 2 ASSESSMENT AFTER 12 MONTHS N.C

BARTH EV

MEC

MEC

LAWT

C.D.T.

2 LAWT

95

2

5

2

C.D.T.

S. CUID

18

0 BARTH EV

18

G.C.I. FAM

95

2

G.C.I. FAM

2

S. CUID

C.V.

0

5

S. CUID

C.V.

0

8

As you can see, advances were made in the improvement of cognitive aspects. This improvement 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 many ink 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 successes which he had acheived not only in his cognitive rehabilitation but also (and more importantly) in his everyday life.

5.- CONCLUSION: This case shows the benefits that can be reaped from cognitive rehabilitation with people who present memory problems, firstly with regard to cognitive processing and secondly with regard to their everyday life development (Franco y cols., 1998). Taking advantage of the resources that information technology can provide when it comes to presenting 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 a patient and a computer with a touch sensitive monitor), a new tool which appears at first glance to be something which could never be useful to people with cognitive difficulties, can be seen as a potential reinforcer in rehabilitation. Likewise, given such a new presentation as far as the elderly are concerned, this kind of program foments greater motivation when it comes to discovering "What else will it show me", and with that, continuity, an indispensable aspect in good rehabilitatory practice, is aumented.

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6.- BIBLIOGRAPHY

FOLSTEIN, M.; FOLSTEIN, S.; McHUGH, P.R. Mini-mental state: a practical method for grading the cognitive state of patients for the clinician. J. Psychiat. Res. 1975; 12: 189-198. FRANCO, M.A.; ORIHUELA, T.; BUENO, Y.; MONFORTE, J. Rehabilitación cognitiva por ordenador: Programa AIRE. Rev. Informática y Salud, 1998, 15: 764-766. FRANCO, M.A.; ORIHUELA, T.; BUENO, Y.; CID, T. Programa Gradior. Carácterísticas generales. Zamora, Edintras, 2000. FREEMAN, M.; LEACH, L.; KAPLAN, E.; WINOCUR, G.; SHULMAN, K.L. Y DELIS, D.C. Clock dawing. A neuropsichological analysis. Nueva York: Oxford University Press, 1994. GUY W. Assessment Manual from Psychopaharmacology. Departament of Health an Human services, Public Health Service, Alcohol Drug Abuse Administration, NIMH Psucyopharmacology Research Branch, Rockville, MD: ECDECU 1976: 218-222. HUNT, S.M.; MC. EWEN, J. The development of a Subjetive Health Indicator Social Health Illness. 1980; 2: 231-246. JORM, A.F., JACOMB, P.A. The Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE): Socio-demographic correlates, realiability, validity and some norms. Psychol. Med. 1989; 19: 1015-1022. 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, New York 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 lusoespañolas de Neurología, Psiquiatría y Ciencias afines. 1979; 3: 189-202. LOBO, A.; ESCOLAR, V.; ESQUERRA, J.; SEVA, A. Mini-Examen Cognoscitivo: un test sencillo 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 the elderly in Spain: prevalence of disorder and validity of screening. Int. J. Geriatr. Psychiatr. 1990; 5: 83-91. MAHONEY, F.I.; BARTHEL, D.W. Functional evaluation: The Barthel Index. Md State Med J 1965; 14: 61-65. 4


MORALES, J.M., MONTALVO, J.I., SER, T., BERMEJO, F. Estudio de validaci贸n del SIQCODE: la versi贸n espa帽ola del Informant Questionnaire on Cognitive Decline in the Elderly. Arch. Neurobiol. 1992; 55: 262-266. ROSEN, W.G., MOHS, R.C., DAVIS, K.L. A new rating scale for Alzheimer麓s disease. Am J Psychiatr 1984; 141: 1356-1364. ZARIT, S.H., REEVER, K.E., BACH-PETERSON, J. Relatives of the impaired elderly: Correlates of feelings of burden. Gerontologist 1980; 20: 649-655.

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Gradior: a practical case study.