Cognitive Changes are Common in Parkinson’s
Cognitive difficulties are a common non-motor symptom in Parkinson’s disease (PD) and can affect many facets of everyday life. Executive function, or the ability to plan and organize multi-step activities can specifically be affected in PD. Visuo-spatial skills, which allow a person to navigate in three dimensions, estimating distances and maneuvering around obstacles, can also be impacted. In addition, memory, attention, and language can be impaired as well. Although there are medications that can be prescribed, the cognitive benefits of these medications in clinical research studies have been modest.
Cognitive rehabilitation is a collection of different types of therapies that aim to improve cognition. An occupational therapist typically performs this type of rehabilitation.
Our conversation with Dr. Erin Foster
We spoke with Dr. Erin Foster to learn more about occupational therapy and how it can help people with PD. Dr. Foster is an Associate Professor of Occupational Therapy, Neurology, and Psychiatry at Washington University School of Medicine in St. Louis, MO. She directs the Cognitive and Occupational Performance Laboratory, which generates knowledge to guide the development of more effective and comprehensive rehabilitation programs for people with neurological disorders and cognitive dysfunction, including PD.
Q: What is cognitive rehabilitation? What problems does it address?
A: Cognitive rehabilitation refers to interventions that aim to improve or maintain a person’s participation in daily life activities and roles by improving cognitive function. There are different approaches to cognitive rehab:
- Restorative training (also referred to as remedial or process): aims to improve or strengthen specific cognitive skills like attention or memory through repetitive practice of tasks that challenge those skills. An example of this approach is computerized brain training games.
- Strategy-based approaches (also referred to as compensatory): address everyday function more directly by training the use of strategies to work through or around cognitive challenges and accomplish daily activities. Such strategies can range from external devices like memory notebooks and medication alarms, to “internal” strategies like self-cueing and pacing, to more general planning, time management or organizational strategies for navigating daily activities and routines.
In addition to my clinical interests, my research focuses on these types of strategies and their efficacy in PD. There is variation within and overlap among different approaches to cognitive rehab, and clinicians may employ multiple approaches depending on the person’s cognitive and functional strengths, limitations, and goals.
Almost all aspects of daily life involve cognition, so cognitive rehab can address a multitude of problems in everyday function. It can address work- or job-related challenges, issues related to safe and independent functioning at home and in the community, and engagement in cognitively challenging activities including social and leisure pursuits.
Q: If I am prescribed a course of cognitive rehab, what should I expect on my first visit?
A: You should expect a thorough evaluation of your cognition, with a focus on how it affects your everyday life. This may include neuropsychological testing, such as paper-and-pencil, verbal, or computerized tests of basic cognitive skills like executive function, memory, and attention. Perhaps more important is the assessment of how you integrate and apply your cognitive skills to perform complex, cognitively demanding daily activities. This information can be obtained by tests that involve performing real-life-like functional tasks, such as shopping, medication management, meal preparation, financial management, or scheduling. It is also critical for the therapist to conduct an interview with you – and your care partner if possible – about your daily life cognitive function, including your perceived cognitive strengths, challenges, concerns, and goals. This should then guide you and your therapist to collaborate in forming realistic and meaningful goals for your course of cognitive rehab and an appropriate treatment plan to reach them.
Q: What constitutes a typical course of cognitive rehab – how many sessions and how long is each session?
A: Currently, there is no typical “dose” of cognitive rehab for people with PD. Ideally, and just like other forms of rehab, the treatment plan should be tailored to the person’s needs, trajectory of progress, and goal achievement. To give a general idea, you might expect something like weekly or twice-weekly hour-long sessions over the course of a few months. Therapists may also prescribe “homework” or practice to do in between treatment sessions or activities to continue after the course of rehab to maintain or enhance benefits. In addition, people can always return to therapy for “booster” treatments or as their needs change over time. It is also worth noting that within a course of occupational therapy, treatment for cognitive concerns can co-occur with treatment focusing on other functional limitations (e.g., mobility, self-care, sleep).
Q: What types of improvements can be reasonably expected from a course of cognitive rehab?
A: The evidence for cognitive rehab for people with PD is still emerging. It appears that restorative cognitive training can produce short-term improvements in the cognitive skills trained, but the sustainability of those improvements and whether they transfer to improved daily function are not yet known. There are clues that strategy-based approaches that target daily life activities may produce benefits for everyday function, but studies on these approaches are currently limited. Cognitive rehab can also help you figure out how to maintain participation in your existing daily activities and roles and/or find other ways to remain mentally engaged and stimulated throughout your day. A cognitively engaged lifestyle is thought to protect cognition from neurodegeneration and thus may potentially delay or slow cognitive decline associated with PD.
Q: What should prompt someone to ask for a referral for cognitive rehab?
A: The following are examples of situations in which cognitive rehab may be right for you:
- You or your care partner have noticed changes in your thinking or memory or have any concerns or questions about your cognition.
- You experience difficulty, slowness, or reduced efficiency in daily situations or activities that require planning, organization, multitasking, making decisions, solving problems, thinking quickly, etc. (e.g., managing your household and family responsibilities, maintaining your health, engaging in social activities and interactions, planning your day or week).
- You or your care partner have noticed that you are starting to withdraw from more cognitively demanding activities or are doing less than you used to.
Even if you have no current cognitive concerns, consultation with an occupational therapist can be helpful to plan or learn strategies to potentially delay functional decline. As with any therapy for PD, it is never too early to think about cognitive rehab!
Tips and Takeaways
- Cognitive rehabilitation is collection of different types of therapies, typically performed by an occupational therapist that aim to improve cognition.
- Cognitive rehabilitation can focus on improving functioning at home or at work.
- Consider cognitive rehabilitation if you or your care partner have noticed changes in your ability to perform activities that require planning, organization or problem solving or if you are withdrawing for cognitively challenging activities.
- APDA’s Cognitive Changes in Parkinson’s Disease fact sheet and our Dr. Gilbert Hosts: Cognition & Parkinson’s Disease episode are helpful resources if you want to learn more about potential changes in cognition that can be associated with PD.