Article Archive
November/December 2014

Interventions Slow Brain Atrophy
By James Siberski, MS, CMC; Carol Siberski, MS, CRmT, C-GCM; and Krista J. Randall, MS, OTR/L, CRmT
Today's Geriatric Medicine
Vol. 7 No. 6 P. 18

Specialized intervention can maximize cognitively impaired patients' ability to control cognitive and functional demands to the greatest possible extent.

Countless elderly in nursing homes and hospitals, as well as those being cared for by family and professional caregivers in their homes, experience functional and cognitive atrophy. For various reasons, care providers, whether family members, professionals, or volunteers, perform numerous simple cognitive and functional tasks that patients are capable of executing on their own. Many do it to reduce the time it takes to perform a functional skill, such as putting on a pair of shoes.

Because of inadequate training or a lack of information, some caregivers may fail to recognize the negative results of performing tasks for patients rather than allowing them to do things for themselves when they retain the ability to complete various tasks. Others, in an attempt to protect patients from the embarrassment of not knowing a correct reply to a question, provide answers to questions addressed to patients who actually knew the reply but were slow in processing and responding.

Brain atrophy, defined as the loss of ability to function and attributable to factors other than those due to the dementia, disease, or illness, causes excess disability. This disability increases the amount of care and effort required from care providers and diminishes a patient's quality of life. Patients with neurocognitive disorders, whether major or minor and depending on the cause of the disorder, retain many functional or cognitive abilities that can be utilized in preventing excess disability.

Maximizing Function
A patient with a major neurocognitive disorder resulting from Alzheimer's disease, for example, retains cognitive and functional abilities (eg, the ability to sing, read, express emotions, tie shoes, and even make coffee if the steps are sequenced for her). Because the retained abilities vary from patient to patient, a competent assessment is necessary in order to allow patients to exert maximum control of their cognitive and functional demands if given the opportunity and time to perform the required actions and activities. It is important for as long as possible to encourage patients to perform those actions and activities that rely on any and all retained abilities, which could also be called strengths, in order to optimize independence.

Strengths, such as the ability to communicate, act as a member of a group, make decisions, remember past events, remain as oriented to reality as possible, contribute to a conversation, maintain integrity over a lifetime, and remain involved in the community and family life, are psychosocial aspects of a patient's quality of life that can be lost to atrophy and thus create excess disability.

Primary health care providers are positioned to recommend to families, facilities, occupational therapists, recreational therapists, and paraprofessionals the interventions that can assist patients in maintaining the highest possible quality of life and psychosocial functioning. Physicians, nurse practitioners, and physician assistants can recommend interventions such as remotivation therapy, reality orientation, sensory training, and reminiscing therapy as effective means to prevent atrophy and excess disability.

Sensory training, originated by Leona Richman, is used effectively with older adults who display an inability to interact with their environments and a disorientation to their bodies. It is employed with individuals who are significantly impaired both functionally and cognitively. One of the therapy's strengths is its structure. Its goal is to bring patients back in touch with their surroundings through a series of graded exercises. Conducted in a group of five to eight patients, it is appropriate for very low-functioning or cognitively impaired patients. Staff, family, and even volunteers can easily be trained to conduct sensory training groups.

Reality orientation, an intervention used with moderately confused patients, uses repetition and relearning for those who are disoriented to time, place, person, and situation. The goal is to heighten the sense of reality by providing patients with constant accurate information about themselves and their environment. Reality orientation, provided in a group setting, can be utilized on a 24-hour basis in facilities, is easy to learn, and can be used by all trained staff, family, and visitors.

Reminiscing therapy requires little training. Robert N. Butler, MD, who defined reminiscence, stated that it occurs when an individual recalls long-forgotten incidents and dwells on them, recapturing the emotions that originally accompanied them. Anyone who possesses listening skills can be involved in directing reminiscing therapy. This intervention allows an individual to reconnect with or rediscover memories that have been forgotten or pushed aside by illness. It's important to encourage reminiscing with older individuals so that they can engage in a life review process that, according to Butler, is a normal developmental occurrence in which past experiences, many of which may be unresolved conflicts, are recalled. The goal of the personal life review is to successfully reintegrate these memories, thereby giving a new meaning or significance to elders' lives as death approaches.

While remotivation therapy is typically conducted in groups of six to eight, it can also be utilized on a one-to-one basis. As a simple group therapy, it maintains an objective nature (ie, topics such as sex, politics, religion, and other topics on which individuals would have a strong subjective opinion are not utilized) that is implemented by trained individuals. It is designed to reach the unwounded areas of a person's life (ie, those not affected by illness, such as retained cognitive and functional abilities) and to encourage the individuals to focus on these aspects of their lives.

The trained individual, whether a professional, paraprofessional, volunteer, or family member, uses various types of questions to reach these unwounded areas. Oftentimes, pathology such as Alzheimer's disease, schizophrenia, pain, and normal age-related losses drive the unwounded, healthy aspects of a person's life and personality outside of awareness. The remotivation therapist taps into these buried or dormant areas and reestablishes the individual's interest in them by aiding in rediscovering this hidden aspect of him- or herself.

Remotivation is a simple five-step structure created by Dorothy Hoskins Smith that begins with a climate of acceptance, meaning that the person conducting the therapy accepts the individual's responses or behaviors, within reason. If, for example, the patient should decide to stand up to leave, the therapist would ask him or her to return if able, setting an expectation but accepting the behavior.
The second step introduces a topic by asking general questions that narrow to a specific topic. Step three explores the identified topic in general through group discussion of the topic by asking "who, what, where, and when" questions. The fourth step covers the work aspect of the topic by asking "how" questions; that is, what work may be involved in the topic. The fifth and final step, a climate of appreciation, serves to summarize and close.

Is remotivation therapy effective? One of the authors of this article witnessed the results of remotivation in her initial role as an occupational therapy student working with patient groups. Occupational therapy students learn various intervention strategies and techniques throughout the course of their university education with the intention of providing patients with the best quality of care. Remotivation therapy is a therapeutic technique that can be added to any therapist's "toolbox."

With numerous hours of training in remotivation therapy and certification as a remotivation therapist through the National Remotivation Therapy Organization, the article's coauthor notes that at one of her occupational therapy field work sites, a Maryland veterans hospital, remotivation was utilized with an older adult population of veterans with various psychosocial and cognitive disorders such as schizophrenia, schizoaffective disorder, dementia, and posttraumatic stress disorder, among others. These veterans engaged in remotivation therapy twice per week for approximately eight successive weeks. The supervisor at the facility encouraged the implementation of this technique during group therapy and was interested in the unique approach that remotivation therapy offered.

Remotivation therapy offered the veterans' group structure, the ability to overcome vocational challenges, and improvement in the awareness of reality in relation to themselves and those around them. The response to remotivation that was detected by the supervisor, the veterans' family members, and the nursing staff at the veterans' hospital was undeniable. First, the supervisor observed a change in interpersonal skills, volition, body language, and self-esteem among the veterans, which had not been evident for a long period of time prior to remotivation therapy.

Second, one family member was made aware of the vast changes her brother displayed and was ecstatic about his progress in engaging in therapy, initiating conversation with others, and fulfilling a leadership role by serving coffee to the other residents. Third, when the nursing staff at the veterans' hospital witnessed the veterans engaging in remotivation, they were amazed at the increase in their social participation and attentiveness. As the nursing staff observed the veterans in remotivation, they were inclined to facilitate more conversation and activities outside of group therapy for the veterans as they were aware of their improved abilities.

There was a noticeable improvement in the veterans' social participation skills, cognitive skills such as orientation and attention span, and thought functions such as awareness of reality. However, these results do not occur after only one or two weeks. In fact, based on the experience of the authors, the noted interventions take approximately three to five weeks to begin to show results.

Final Thoughts
The old saying, "use it or lose it," although true as it relates to the human brain, is a bit of an oversimplification. Patients use skills, abilities, and strengths in all of the previously mentioned therapies. Their verbalizing in response to questions, perceiving the therapist or visual aids, and even shaking the therapist's hand, require brain function. If a patient does not shake hands, articulate or view the visual aids, or have the opportunity to be engaged in this manner, these skills and abilities will eventually atrophy and he or she can lose the abilities or they will diminish over time.

Although these therapies will neither cure an individual's ailments nor replace advanced therapies such as pharmacotherapy, cognitive behavioral therapy, stress reduction, and occupational therapy, they do contribute to orienting individuals to themselves and to the environment as well as to time, place, person, and situation, and can slow or prevent the atrophy of verbal and group skills and the erosion of memories not caused by the disease.

Therapists need to be compelling advocates for these therapeutic techniques, including remotivation therapy, and aspire to utilize these techniques when treating older adults with psychosocial and cognitive disorders. Health care has moved to a community-based model, and remotivation is an effective therapeutic tool for individuals in nursing homes, senior centers, day care programs, and other facilities to improve older adults' cognitive, physical, and psychosocial functions. Health care professionals must increase their understanding of effective intervention strategies and implement them in patients' lives in an attempt to improve their quality and quantity of life. By successfully preventing atrophy, individuals will experience less excess disability and therefore will be in the position of doing more for themselves and decrease the demands on caregivers, ideally reducing their stress level.

Each session of remotivation therapy, reminiscing groups, sensory training, or reality orientation engages the group members. Because of the emphasis placed on the brain health of the elderly and the baby boomer generation, therapists need to be cognizant of how their efforts impact a patient's brain and cognitive functioning.

It is imperative that therapists carefully assess individuals who participate in any of the interventions discussed here. If, for example, an individual who is disoriented to his or her environment were to be placed in remotivation therapy, the results would be poor at best because he or she would lack the prerequisite skills or abilities to succeed in the remotivation therapy intervention. The therapist providing intervention also needs to observe and evaluate an individual's sensory modalities.
If the individual has poor hearing and cannot understand the therapist's words or failing eyesight creates the inability to relate to a visual aid, it will impede therapy and any potential success the individual might experience.

— James Siberski, MS, CMC, is an assistant professor of gerontology and the director of the geriatric care management graduate certificate program at Misericordia University in Dallas, Pennsylvania. He is also an adjunct faculty member at University of Scranton.

— Carol Siberski, MS, CRmT, C-GCM, is a geriatric care manager in private practice and conducts research in geriatrics and intellectual disabilities in Pennsylvania.

— Krista J. Randall, MS, OTR/L, CRmT, is an occupational therapist at MedStar Franklin Square Medical Center in Baltimore.


Remotivation Therapy With AD Patients
Remotivation is not a treatment that cures the disability. As with other forms of physical rehabilitation, a patient learns to make accommodations to his or her disability. Cognitive diseases or disabilities are not yet curable by modern medicine. While researchers continue to search for medications that reduce memory loss and disordered thinking, medical care provided to those with chronic conditions consists of therapies or programs that help people function at their highest level and live a meaningful life with the disability.

Remotivation is one of those therapies or programs that maximize abilities. It works with the "unwounded personality or self," focusing on what patients can do rather than what they cannot do.

Therefore, remotivation can complement traditional treatment with medications and diet to help people maintain functioning and use the capabilities they have to live life.

How does remotivation work with the unwounded or healthy parts of an individual? Trained individuals utilize discussion plans that incorporate the five steps of remotivation therapy, which adjust the discussion to focus on a patient's remaining abilities, including the following:

• climate of acceptance;

• bridge to reality;

• sharing the world in which we live;

• exploring the work of the world; and

• climate of appreciation.

Incorporated into these steps are the use of association, open-ended questioning from the abstract to the concrete and from the subjective to objective. Remotivation also uses various art forms, such as written, verbal, and visual pictures or poems to help reach an individual's healthy remaining abilities.

Research over the course of 60 years demonstrates the effectiveness of remotivation therapy to help individuals with cognitive disability, severe mental illness, mental retardation/learning disabilities, and other forms of neurological impairment.
For more information, see

— Source: National Remotivation Therapy Organization