Integrating Cognitive Challenges into Everyday Treatment
Published: 04 May 2015
Published: 04 May 2015
Health care providers are human. We fall into routines, patterns—lethargy even. Unfortunately, when we do the same treatments day-after-day, we don’t always bring our A-game. Take physiotherapists. Physios love the number 10 and 2—as in “10 reps and 2 sets”. Sometimes we fall into a rut, calling out “10 times” when it’s obvious that 10 reps will neither challenge the patient nor allow adequate time for a cappuccino for the therapist (joking of course).
“Don’t you know any number other than 10?” a disgruntled patient once asked me. “I know 20,” was my singularly pithy reply. But I was bluffing. We did another set. Of 10.
Sure, one of the easiest ways to progress with any exercise is to do it for a longer period of time. But rote repetition isn’t highly effective at enhancing skill, because the human body adapts remarkably well to predictability. In a surprisingly short time, it is no longer taxed by reps and sets. What it requires is a bigger challenge—something that will cause the brain to be pushed into uncharted waters. Enter cognitive challenges. One of the best ways to introduce challenge into the patient’s treatment is to incorporate a cognitive processing element. Decades of research has shown that dual-task performance (the simultaneous performance of two or more tasks) is exceedingly more challenging than single-task performance.
To put it simply, trying to think while we do stretches us. Keep in mind that dual-task challenges are not just fodder for therapists anymore. The more effort any health care provider puts into tapping into mental reservoirs, the more the patient will benefit. Fortunately, these concepts are quite simple to execute. To get you started, here are a number of examples from the field where you can integrate cognitive challenges into your patient’s daily routine.
Basic interaction: The patient and family meet with a social worker, therapist, and nursing representative. The health care team speaks predominantly to the family or asks simple “yes/no” queries of the patient.
Cognitive enhancement: Conferences are an ideal time to tease out how much the patient understands about their care. If the meeting is geared around a discharge plan, the patient should be asked direct, open-ended questions, such as:
Even though the family can provide many of these answers (and perhaps much faster), the first query should often go to the patient.
Basic interaction: The patient is wheeled or walked from point A to point B.
Cognitive enhancement: Transport time is the perfect opportunity for pathfinding exercises. When the elevator doors open and the patient finds themself back on “home turf”, it’s a great opportunity to ask, “If you don’t mind, direct me back to your room. Should I turn here or here?” (Wait for direction. If direction is wrong, stop and prompt.)
Basic interaction: The patient is transferred by 1 or more individuals using good body mechanics to reduce the likelihood of injury.
Cognitive enhancement: Transfers happen dozens of times each day. It’s an ideal time to integrate dual-task programming. The reason for this is that transfers are often done in a manner which is foreign to the natural instincts of the patient, meaning that a greater load of the work is borne by the nursing staff. Haven’t you ever wondered why there is such a discrepancy between the transfer level assigned by the physio (moderate assist of 1) and the transfer level used by nursing (maximal assist of 2)?
To introduce a cognitive challenge, ask the patient to problem-solve the transfer. “Where do you want me to stand? What will make getting up easier on you?” (Wait for an answer, but prompt with ideas such as: should you scoot to edge of seat, lean weight forward, use rocking for momentum?)
Basic interaction: The patient walks from point A to point B.
Cognitive enhancement: Whether it’s performed in the patient’s room or in the rehab department, gait time should be cognitive time. Have the patient ambulate while counting backwards from 30… by threes. Or verbally describe the drive to work (for example; after I turn right out of my driveway, I go through the neighbourhood until I arrive at the roundabout.) Or ask the patient to describe the best way to eat a Tim Tam. There are dozens of other dual-task ideas that all have a similar goal: they make gait and balance training a challenge merely by adding a cognitive element.
Basic interaction: A nurse enters the room at shift change and writes their name on the patient’s board. The patient is asked yes or no questions, such as “Do you understand?” instead of open-ended questions.
Cognitive enhancement: Shift change can be a good opportunity to assess the alertness and clarity of the patient. Instead of putting the patient in a passive receptive mode, switch the tables. The conversation becomes: “Hi, I am Nancy and I am taking over from Ruby as your nurse. Can you tell me what you prefer to be called?” Wait for a response. “Feel free to call me by my first name, too. Just ask for…” (Point to self and wait for response). “I can write it on the board to help you remember it.” Note: it doesn’t have to sound scripted. Make it your own language, but make sure you are not compromising the patient’s opportunity to process and verbalize.
Basic interaction: A nurse hands a patient their medicines in a cup and then hands the patient a drink and waits for the patient to swallow the medications.
Cognitive enhancement: This is a hard one because the time crunch on nurses during medication distribution is so limited. But whenever possible, introduce cognitive bits and pieces. “I’m giving you the yellow pills first. You were taking those at home. Can you tell me what they are for?” Or, “This is the first time today you are getting the big purple pill. At home, do you take it once or twice each day?”
Basic interaction: A nurse’s aide washes a patients face, brushes their hair and cleans their teeth.
Cognitive enhancement: Self-care can be an excellent time to allow patients to problem-solve, sometimes, it is the only way that patients feel that they are taking any responsibility for their own body. Instead of doing for the patient, lay out the self-care items. Ask the patient what they would like to do first. Wait. If no action is initiated, ask again. Help only when the patient is stuck or asks for help. Do not remove the opportunity to problem-solve and participate.
There is almost no aspect of patient care where it is impossible to add some element of cognitive challenge. For more ideas consider reading Silsupadol et al.’s excellent study on dual-task balance training (especially Appendix B). The research is clear: the introduction of a mental challenge stretches patients whether they have suffered a TBI, a stroke, diabetes or lie in the intensive care unit.