Many cognitive rehabilitation methods focus on training for a particular aspect of cognitive deficits, and attention should be paid to the purpose and interest of the training. Before rehabilitation training, cognitive dysfunction should be analyzed and classified according to the results of cognitive rehabilitation assessment, and then a rehabilitation plan should be formulated in a targeted manner. Generally, cognitive dysfunction is classified into the following categories: intellectual impairment, memory impairment, attention impairment, visuospatial impairment, language impairment and emotional response impairment.
In the process of rehabilitation training, the rehabilitation physician must also adjust the difficulty and content of training according to the progress of the patient’s cognitive deficits, in accordance with the principle of gradual progress, repeatedly and gradually consolidate the training results in order to obtain satisfactory rehabilitation results. Since the mechanisms of occurrence and manifestations of various cognitive dysfunctions are different, the rehabilitation models chosen are also very different.
I. Definition of dementia
Alzheimer’s disease is a syndrome characterized by cognitive, behavioral and personality changes caused by brain dysfunction in the elderly. It is an acquired and persistent intellectual impairment.
II. Types and characteristics of Alzheimer’s disease
Alzheimer’s disease can be divided into the following three types according to its symptoms and the mechanism of its production.
1.Alzheimer’s dementia
In the early stage, the most common symptom is near-memory impairment, followed by suspicion as the first symptom; when the disease develops further, the calculation ability decreases, and there may be cognitive impairment, and gradually the understanding and judgment of daily life and common sense also become impaired; in the late stage, the patient is completely bedridden and depends on others to take care of him/her, and the disease lasts for about 5-10 years and dies.
2.Vascular dementia
The onset of the disease is rapid, with a history of recurrent, multiple small stroke episodes, mostly seen in the 60s, and half of the patients have a history of hypertension. The disease progresses in a stepwise manner, i.e., the symptoms of dementia worsen with each stroke attack.
3. Mixed dementia
Symptoms of both Alzheimer’s disease and vascular dementia are present, and sometimes it is difficult to identify them.
How to diagnose?
Currently, the international diagnostic criteria for Alzheimer’s disease, as revised for the tenth time in 1992 (ICD-10), are mostly used.
(1) Dementia is present.
(2) Latent onset, slow change, often difficult to specify the time of onset, but others may suddenly notice the presence of symptoms. During progressive development, a period of relative stability may occur.
(3) There is no clinical basis or specific examination findings that would suggest that the mental disorder is due to other systemic or brain disorders that can cause dementia (e.g., hypothyroidism, hypercalcemia, vitamin B12 deficiency, niacin deficiency, neurosyphilis, normal pressure hydrocephalus, or subdural hematoma).
(4) Lack of sudden, stroke-like onset and absence of signs of focal neurological damage early in the disease, such as limb palsy, sensory loss, visual field deficits, and poor motor coordination (although these symptoms will appear later in the disease).
Dementia can be determined by various dementia scales such as MMSE, HDS, HIS, and ADL, and in conjunction with clinical manifestations to determine the presence of dementia or suspected dementia, whether it is Alzheimer’s type or vascular dementia, the degree of dementia, and the ability to perform daily living with dementia.
Third, the significance of dementia rehabilitation training
1.Alzheimer’s rehabilitation training is the process of solving a series of problems for Alzheimer’s patients.
2. The purpose is to reduce the negative impact of Alzheimer’s disease on the patients themselves, their families, friends and related people.
The key is the four-pronged effort of medical workers, family members, society and the Alzheimer’s patients themselves.
Cognitive therapy
Biofeedback therapy is to learn to consciously self-regulate these biological activities by recognizing and experiencing the signals of changes in these activities, so as to achieve the purpose of adjusting the function of the body and preventing and curing the disease. In fact, it is a cognitive-behavioral therapy to change one’s internal response through learning.
It has been shown that disturbances in hippocampal cholesterol metabolism are responsible for the impairment of synaptic plasticity and the appearance of AB deposition in Alzheimer’s disease. Biofeedback is a better training method to restore neuronal and synaptic conduction function, and may be able to improve hippocampal cholesterol metabolism disorders and synaptic plasticity impairment. The integration of biofeedback therapy into the rehabilitation of Alzheimer’s disease can increase the cognitive ability and central neuron function of patients through feedback overlay technique.
1.Rehabilitation Training Memory Training
(1) Memory training
Memory impairment is the main clinical manifestation. The early stage shows near memory impairment, the middle stage shows distant memory impairment, and the late stage shows total memory loss. Memory training can maintain the original memory or delay the further decline of memory.
Memory training is known as a “gymnastic exercise” for brain cells. Regularly do this “gymnastics”, can prevent brain aging, is a good recipe for brain health. Epidemiological surveys have found that the incidence of Alzheimer’s disease is significantly lower in the elderly with high literacy than in those with low literacy.
Memory training for Alzheimer’s patients should focus on the process of training rather than the result of training. That is, it is not necessary to make the patient remember much, but rather to make the patient participate in the training and use his or her brain.
(2) Notes on the process of memory training
The difficulty of the training should be selected according to the actual situation of the patient. If the difficulty is too high, on the one hand, the patient will not be able to complete it, on the other hand, it increases the mental burden of the patient and causes adverse emotional reactions; the patient will not only refuse to cooperate with the training, but some of them will even have psychological shadows.
The choice of picture categories should be based on the type of memory impairment of the patient: for example, if the patient has memory impairment of people, he should choose pictures of people for memory rehabilitation training; if the patient has memory impairment of daily necessities, he should choose pictures of daily necessities for memory rehabilitation training.
The type and difficulty of pictures should be chosen according to the degree of memory impairment: patients with not very serious memory impairment: pictures of landscapes and animals can be chosen. Patients with more severe memory impairment should choose pictures of “everyday objects”. Patients with severe memory impairment should select the “memory of loved ones” function provided by the system to train patients’ ability to remember the appearance of their loved ones.
In the selection of memory training pictures, when we choose the memory pictures that are familiar to the elderly, the effect of memory training will not be achieved. However, when all the memory training pictures were replaced with pictures unfamiliar to the elderly, it was found that the patients often could not remember any of them due to the large decline of near memory in Alzheimer’s patients, which seriously affected the confidence of the patients to carry out the treatment.
Therefore, mixing familiar pictures with unfamiliar pictures for memory training can ensure the effectiveness of memory training and the confidence and motivation of patients to participate in treatment. In the process of memory training rehabilitation, we use a modified error-free learning method. Error-free learning is the elimination of errors in learning. The learner starts with easily identifiable items and is kept from experiencing failure by gradually increasing the difficulty of the assignment.
Error-free learning is a technique that eliminates errors during training. It differs from traditional forms of learning. Traditional forms of learning encourage “guessing,” so many mistakes are made unintentionally. Error-free learning is the reduction or elimination of incorrect or inappropriate responses during training.
There are two important characteristics of error-free learning:
First, error-free learning is not a specific treatment. It is a training technique that is used throughout the learning process. When undergoing this type of learning, the opportunity to make mistakes is not given, and the erroneous responses that occur during traditional learning can be avoided.
Second, training is done to avoid making errors by giving the learner the correct answer directly or by having the patient perform tasks that are easily impossible to make errors. Standardized error-free learning involves the therapist directly telling the patient the correct answer and asking him or her to remember it. Modified error-free learning is where the therapist describes the problem using a rich semantic vocabulary and uses semantic clues to elicit the correct answer from the patient. The modified error-free learning method, on the one hand, avoids the interference of correct information due to guessed error information, and on the other hand, enables the patient to actively participate in the training learning and get more correct stimuli from the learning, which can better improve the memory ability.
(3) Memory training with images of relatives
A digital camera is used to take pictures of people who are closer to the patient, and then recording equipment can be used to dub the images. The picture files are saved into the computer together with the sound files. The patient can then be trained to remember the picture of the loved one. Long-term memory training can also be conducted: a previous picture of the patient is entered into the computer, and the picture can be displayed during training, and the patient is asked questions by the rehabilitation physician, and the patient is asked to recall the answers. This method stimulates the patient’s recall of the time, place, person, and environment associated with the photograph. In the process of recall, the patient’s brain function can be trained to achieve the purpose of long-term memory function training.
2.Intellectual training
Intellectual training and memory training are closely integrated. The good effect of intellectual training will promote the improvement of memory function, and the improvement of memory function will further promote the recovery of intelligence of Alzheimer’s patients. Intellectual training is a very important part of the rehabilitation training for Alzheimer’s patients and plays an important role in the treatment of Alzheimer’s disease. Intellectual training is divided into five areas: observation, classification of natural things, numerical and mathematical calculation, visual-spatial recognition and imagination.
3.Observation ability
Observation is a kind of organized and comparative persistent perception according to a certain purpose; it is based on the process of perception, but it already has the “color of thinking”, and is the highest form of perception. Observation is a solid cognitive ability formed in the process of purposeful, organized and thoughtful perception, and is an important factor in the composition of intelligence. Appropriate games are designed to improve patients’ observation skills. Such as: everyone find the mistake, hidden ring, find the difference, find the cockroach, find the word, hide-and-seek.
4.The ability to classify natural things
Classification is to divide things into groups according to certain criteria, that is, a method of thinking into different categories. The essence of classification is to recognize the differences and connections between things. Classification is derived from the comparison, and is closely linked to the generalization. Generally speaking, only after generalizing the common properties (general or essential properties) among different things, can things be classified. The process of classification is also accompanied by generalization and concept formation. The ability to classify has an important influence on the organization, structuring and systematization of knowledge and experience, and training the classification ability of Alzheimer’s patients is one of the important aspects of intelligence development. Appropriate games are designed to improve patients’ ability to classify natural things. Such as: fruit classification, vegetable classification, kitchenware classification, car classification, etc.
5.Numerical and mathematical calculation ability
Mainly refers to the patient’s ability of mathematical logic thinking in the understanding of the concept of number and simple counting operations. Appropriate design of some games to improve the patient’s numerical and mathematical calculation ability. For example: mathematical calculation, counting watermelons, counting strawberries, grocery shopping, counting tools, counting seals, counting insects.
6.Visual-spatial recognition ability
Spatial ability is the ability of people to reflect the spatial relationship of objects in the objective world. Spatial ability mainly includes two aspects: one is spatial perception ability, and the other is spatial imagination ability. Spatial perception ability includes shape perception, size perception, depth and distance perception, orientation perception and spatial orientation, etc. Spatial imagination refers to the ability to imagine two-dimensional graphics and three-dimensional spatial features {orientation, distance, depth, shape, size, etc.} and spatial relationships of objects. Some games are appropriately designed to improve patients’ visual-spatial recognition ability. For example: analysis of the top of things, four-piece puzzle, reflection training.
7.Imagination
Imagination is the mental process that people’s original representations in their minds are processed and reassembled to produce new images, which is an advanced and complex cognitive activity. Imagery and novelty are the basic characteristics of imagination activity, which mainly deals with graphic information and presents in people’s mind in an intuitive way, rather than in words, symbols, and concepts. Some games are appropriately designed to improve patients’ imagination. For example: guessing words, worms eating apples, reflecting mirrors, monster guessing, climbing grids, jigsaw puzzles, jigsaw puzzles, dissolving in the same color, pushing boxes, etc.
8.Right brain training
According to foreign data analysis of 1500 cases of senile dementia patients, it is found that 90% of them are aging disuse dementia. This kind of patients in the young period, because the left brain receives more stimulation, the right brain receives less stimulation, causing the right brain relatively underdeveloped; patients are not interested in music, painting, games, lose life goals, low desire.
By using some right brain function training games, the patient can have brain activation training and perceptual stimulation of the right brain posterior desire center, so that the brain function can be improved significantly. For example: mahjong, five-in-a-row, chess, checkers.
9.The use of music therapy in the process of rehabilitation training
Aristotle was the first person to discuss the relationship between music and mind and body. He believed that music could penetrate into the soul and purify the spirit, thus maintaining the balance between mind and body and promoting physical health. After World War II, U.S. military hospitals began using music to treat insomnia, depression, and psychiatric disorders in U.S. military personnel, and the medical profession combined music with physiological phenomena to enhance or accelerate medical effects.
According to Hebb’s research, music acts on the subcortical non-specific reflex system and brainstem reticular formation through the auditory system, which in turn affects cortical function and plays a regulatory role in neurological function. It converts the sound energy of regular acoustic vibrations into a function that restores the dysfunctional state of the brain’s nerve cells to a physiologically necessary balance. Therefore, different types of music have different therapeutic effects. For example, if the mood is unstable and unstable, you can enjoy “Song on the Cypress”, “Spring River Flower Moon Night” and round dance music.
Clinical experience shows that music therapy can enhance the sense of reality of the elderly with dementia, and the sense of reality can provide the elderly with information about authenticity, improve self-perception and increase independence. By having them listen to or sing songs related to the current time, season, environment, and events, the elderly can change their confused thinking. In addition, music stimulates long-term memory and improves short-term memory and other cognitive functions in older adults. The choice of music as background music during rehabilitation training can be used in practice according to the patient’s condition and the actual situation at the time.