1. From Paper and Pencil to iPads: Cutting Edge Ideas and Activities for Cognitive Stimulation Presented at the 2013 International Conference on Active Aging in San Diego, CA Dr. Rob Winningham Western Oregon University

2. Table of Contents Evidence for Cognitive Stimulation – Use It or Lose It – Cognitive Reserve Hypothesis Cognitively Stimulating Activities How to Run Classes – Screening – How often – Where – How long should the classes be – How many participants

3. Cognitive Exercise is the Key Older adults can improve their memory ability with regular cognitive exercise. The “Use It or Lose It” theory is now widely accepted by scientists. The “Reserve Hypothesis” is consistent with the “Use It or Lose It” theory, in that increased neuronal connectivity will lead to better functioning.

4. © 2013, Dr. Rob Winningham All Rights Reserved More Scientific Findings Stimulating jobs are associated with decreased likelihood of having memory problems Having complex and dense ideas early in life is associated with fewer memories problems later (nun study) Increased education is associated with a decreased likelihood of developing Alzheimer’s Disease.

5. © 2013, Dr. Rob Winningham All Rights Reserved Recent Scientific Findings March, 2005 - Higher levels of education are associated with different cognitive courses in AD patients. More education is associated with a relative preservation of attention and verbal processes. Le Carret et al., Universite Victor Segalen

6. Dementia Prevalence is Declining Matthews et al. (2013) reported in the journal Lancet that dementia rates among people 65 and older have plummeted by 25 percent over the past two decades, to 6.2 percent from 8.3 percent, a trend that researchers say is probably occurring across most developed countries. Why? © 2013, Dr. Rob Winningham All Rights Reserved

7. Dementia Prevalence is Declining Possible reasons for the 25% reduction: – Controlling cardiovascular risk factors Cholesterol Blood pressure – Better education and possibly more cognitive stimulation – Greater awareness of the importance of physical exercise © 2013, Dr. Rob Winningham All Rights Reserved

8. 2013 Article in the Journal Neurology Wilson et al. found that people who participated in more mentally stimulating activities had a slower rate of decline in memory. Mental activity accounted for nearly 15 percent of the difference in decline beyond what is explained by brain changes associated with dementia. © 2013, Dr. Rob Winningham All Rights Reserved

9. One of the first controlled studies on cognitive stimulation Average age = 82, average MMSE = 23 Attended 3 sessions per week in their assisted living community. Learned about the brain and memory. Engaged in challenging and fun activities. Exercised many different parts of their brain. Develop better social support networks.

10. © 2013, Dr. Rob Winningham All Rights Reserved One of the first controlled studies on cognitive stimulation Participants in 7 different facilities were tested on many different memory and mental tests. Then 1/2 of the participants engaged in the cognitive enhancement program and the other 1/2 (the control group) did not. Three months later all participants were retested on the same tests. Changes over the three months were analyzed.

11. © 2013, Dr. Rob Winningham All Rights Reserved Memory Ability Increased after Three Months of Cognitive Enhancement Training

12. © 2013, Dr. Rob Winningham All Rights Reserved Journal of Mental Health and Aging Conclusions “If older adults can maintain their cognitive ability, they will require less care and possibly delay or even eliminate the need to go to a nursing home. Cognitively stimulating activities may also postpone symptoms of dementia, which could also delay the need for more intensive care.” Dr. Winningham, Journal of Mental Health and Aging

13. Developing Your Own Cognitive Enhancement Program Not reminiscing (unless used to facilitate social interaction) What is cognitively stimulating? – Simple rule

14. How can a program be implemented? Group-based vs. individual Paper and pencil Computer options – Web based – Site licensed – Kiosk interface – Tablet interface

15. Cognitive Enhancement Activities Use a wide variety of activities Three to six minutes per activity Focus on executive functioning (i.e., attention, concentration and inhibition) in order to maximize generalization to untrained activities and activities of daily living

16. © 2013, Dr. Rob Winningham All Rights Reserved Cognitive Stimulation

17. 5 5 1 9 © 2013, Dr. Rob Winningham All Rights Reserved

19. Buzz Have participants count, beginning in a clockwise direction such that the first person says “one”, the second person say “two” and so on. Instruct people to say “buzz” instead of the number if the number is a multiple of seven (e.g., 7, 14, 21, 28, 35, 42, 49, 56, 63 and so one) or if the number has a seven in the number (e.g., 17, 27, 37, etc.). The direction reverses when someone says buzz in place of the number. Even participants with moderate memory problems can learn this activity, if they do it during every session. This activity requires attention and used the frontal lobes and the right parietal lobe. To make the activity more challenging, split a large group into smaller groups; the noise of the adjacent groups require even greater use of attentional resources.

20. An Idea for More Impaired Participants Say A, B, Cs (or count) in a group and point to the next person in the sequence. Everyone has to engage in sustained attention.

21. Mental Rotation

22. Mental Rotation of Shapes

23. Mental Rotation of Pictures

24. Alphabetization Activities Give each participant an envelope full of words. The participant will dump out the words and attempt to put them in alphabetical order. Variations: For beginners, the first letters of each word should be different and the first letter of each word separated by at least 2 letters in the alphabet (i.e., don’t have words that begin with R and S). For advanced participants, give them words that begin with the same letter or even the first two letters, also try giving them more words.

25. Newspaper Activities The Newspaper Activity actually involves several different tasks. First, get as many newspapers as you have participants. The newspapers don’t necessarily have to be the same; try to get large newspapers (e.g., New York Times or Sunday papers) for high functioning participants and smaller newspapers (e.g., local ones or mid-week papers) for lower functioning participants. Scramble the order of each newspaper, such that all the original pages are there but in random order. Then, give each participant a scrambled paper and ask them to put the pages in the original order, just as they would be in they just purchased the paper.

26. Newspaper Activities After the participants have completed the above task, ask them to find and circles all the ‘m’s on the first page. This task can be made more difficult for non-demented participants by asking them to keep a running total of the number of letters they have circled. They should count aloud so participants have to inhibit listening to others. The task can be made even more difficult by having them find and circle 2 or even 3 letters at a time, which is very appropriate for non-cognitively impaired participants. Then, after the above task is complete. You can give participants scissors, tape, and blank paper. Ask them to cut out words or letters to make a sentence or poem. The participants can tape the words or letters from the newspaper onto the blank paper.

27. Theory of Mind Skit Cartoon Caption Activities – Cartoonbank.com – Have participants match caption with the cartoon. Give them at least three.

28. Ping Pang Pong Always go clockwise. The first person says Ping, the second person says Pang, and the third person simultaneously says Pong and points to someone. The person who has been pointed to starts over and says Ping… Try, snap, crackle, pop…

29. Word Generation Activities A-Z Activity Antonym Activities Name Generation Activities Think of as Many Blank as You Can Think of Things in the Color… Verb Generation Activities

32. A-Z First names Last names Female first names Male first names Animals Countries Verbs Things to are alive Things that are not alive (inanimate objects)

34. Think of as many ________ as you can. Examples: – animals – presidents – flowers – car types – book titles – actors – male names – female names – types of dogs and cats – desserts – countries

35. Generating verbs is a challenging linguistic activity that exercises attention, executive functioning, and word fluency. Recent research suggests that an inability to generate verbs may be a sign of Alzheimer's Disease. Therefore, generating verbs may act in a preventative fashion. This activity is not appropriate for people with some types of dementia. If participants are having a difficult time with this task, remind them that any behavior is ok (e.g., talk, walk, sees)

36. Split Words Begin by printing out sheets linked below, each sheet has approximately 12 words in large font. Cut each word out then cut the word in half. For example, take the word FAMILY and cut it into FAM and ILY. Place all word halves into an envelope. Make enough envelopes for each participant and be sure to label the envelope (e.g., Split Word #1), so you can keep track of which ones you have used and possibly reuse them at other facilities or in 6-12 months. The lists provided are appropriate for people with mild cognitive impairment, they are relative long words and the first letter is capitalized. You can make the task more difficult by using shorter words and/or not capitalizing the first word.

39. Placeholder: picture of Trail making test

43. Homework Cognitive stimulation is probably dose dependent Homework – Important component – How much? At least one assignment per class

44. Anagrams An anagram is word or phrase formed by rearranging the letters of another word or phrase. For example, Elvis to Lives. You now have access to easy and difficult ones. This is a fun addition to any cognitive enhancement program. We also have a related activity called word mines.

45. Difficult Anagrams

46. Easy Anagrams

47. I cnduo't bvleiee taht I culod aulaclty uesdtannrd waht I was rdnaieg. Unisg the icndeblire pweor of the hmuan mnid, aocdcrnig to rseecrah at Cmabrigde Uinervtisy, it dseno't mttaer in waht oderr the lterets in a wrod are, the olny irpoamtnt tihng is taht the frsit and lsat ltteer be in the rhgit pclae. The rset can be a taotl mses and you can sitll raed it whoutit a pboerlm. Tihs is bucseae the huamn mnid deos not raed ervey ltteer by istlef, but the wrod as a wlohe. Aaznmig, huh? Yaeh and I awlyas tghhuot slelinpg was ipmorantt! See if yuor fdreins can raed tihs too.

48. Tangrams

50. Simple Math Problems In this activity participants simply complete 24 simple math problems as fast as they can. You can time participants each time and see if they are improving (i.e., taking less time to complete the math problems). This activity is appropriate for most people regardless of the presence of dementia, as doing simple arithmetic is a procedural memory for most people and not affected by dementia too much (unless there was a stroke that affected a discrete brain area).

51. Developing Your Own Geriatric Wellness Program Screening? Levels?

52. Using iPads for Cognitive Stimulation We recently did a feasibility study using iPads with older adults – Favorite apps – Lessons learned

53. Use a Powerpoint Presentation for Groups People were starting apps before they were explained and not paying attention to instructions Easily made using “screen shots”, powerpoint, and “shapes” in powerpoint (Google the above for instructions)

54. Click on Fit Brains

55. Select the matching pairs

57. The matrixes get larger, but you still just finding the matching pair.

60. Next task instructions are here.

62. Memorize the board, in a moment it will change and you need to click where it changed.

65. Next task instructions are here.

67. Which group of coins has a higher value?

68. This one has the higher value, click on it.

69. Next activity: Instructions are here.

71. The numbers are letters are going to “fall” through the funnel. You will need to determine which ones are missing afterwards.

72. “D” is missing now so click on “D”

74. Instructions for the next activity are here.

76. Your task is to look at the top picture (side view) and choose the bottom picture (top-down view) that corresponds.

78. Next activity: Instructions are here.

80. Click on the number you want to work on.

81. Now 2s are activated. We have a 2 in this row.

82. We also have a 2 in this row.

83. There are no 2s in this subsquare or row. So it has to be here or here.

84. We already have a 2 in this column, so it has to be…

85. Here!

86. Click on the square where you want to add the number and it will light up

88. After the correct square is highlighted, click the number that should go there.

89. Now the number 2 is in the correct spot.

90. Be careful as you only get 3 errors

91. Touch here to open Tetris

92. Touch here

94. We want the descending piece to come down so it makes a complete row, if possible.

95. Move over using finger

96. You can see where it will land.

97. Now wait for it to come down or slide it down with your finger.

98. You can see what the next piece will be.

99. Next piece will appear as soon as the previous one lands.

100. Slide it over with your finger, if it will fit into a row you don’t need to rotate it.

101. This piece should be moved to avoid leaving a gap in the row.

102. …here

103. This one can go straight down.

104. This one can also go straight down

105. But sometimes you will want or need to rotate the piece as it is coming down

106. Tap once to rotate

107. Tap once to rotate this piece clockwise 90 degrees.

108. Rotated 90 degrees.

109. Now we might want to rotate this piece 180 degrees…

110. Slide to the right, tap twice to rotate 180 degrees…

111. …so it fits here

112. Then let it come down.

113. What should we do with this piece?

114. Rotate it 90 degrees with one tap...

115. …slide to left

116. Just like that…

117. Remember that the goal is to get complete rows.

118. If you get a complete row, that row will disappear.

119. If you decide to slide a piece down, don’t remove your finger until it reaches the bottom, or it will rotate.

120. Recommended Apps for Cognitive Stimulation Fit Brains Lumosity Tetris Sudoku2 Memory Block Stroop Effect Visual Attention Brain Lab

121. Lessons Learned from iPad Pilot Project 1.A powerpoint presentation is very helpful in explaining new apps, it also keeps participants looking at the same thing and prevents them from starting at different times. 2.Don’t update apps until class is done. 3.Consider setting up autosynch, so when you download a new app on the primary iPdad it will download to the others.

122. Lessons Learned from iPad Pilot Project 4. Consider having a name, phone number on home screen, in case an iPad is lost. 5. The group-based class might only be for initial learning and then send them off, with occasional meetings and updates. 6. Maybe have an iPad class that meets for other topics and the group members could offer classes for new users.

123. Lessons Learned from iPad Pilot Project 7. Headphones are sometimes needed, but that might make it easier to tune out instructor 8. Males might be more likely to join an iPad class. 9. Consider having a portable battery source. 10. iPad classes can be used in conjunction with paper and pencil brain exercise classes.

124. Screening participants Meet with potential participants Use the MMSE or better yet SLUMS Cut off scores (MMSE) – Advanced 25-26+ – Beginning 16-24 Cut off scores (SLUMS) – Advanced 21-22+ – Beginning 12-20 Personality and social skills Sometimes you will have to turn away a potential participant who could benefit from the class

125. Visually Impaired Consider a separate class Many of the activities can be customized for visually impaired – Buzz – Word generation – Antonyms – Creative brainstorming – Think of as many possible... – Homonyms – Facts of the day

126. Class Levels Try to have two class levels If that is not possible you can challenge more capable participants by: – Ask recall questions – More challenging homework – Extra homework (list of homonyms; think of as many words with the letters M-E-M-O-R-Y) – Have them help run the classes – Have them help lower functioning participants outside of class (e.g., homework or extra activities)

127. Class Levels Have higher functioning participants: – Keep track of attendance – Keep track of homework – Enlist new participants – Develop a newsletter for the class with an article, activities, and pictures – Develop a photograph project New Old

128. Class Levels Have higher functioning participants: – Create a word find (or word search) using other participants’ names – Create a crossword puzzle using facts of the day or facts about participants – Create a jeopardy game using previous facts of the day – Memorize a poem (or a new tongue twister) and recite it for the group. – Develop a book club (librarian?) – Teach a computer class

129. How to Conduct Group-Based Classes A common session – Facts of the Day – Buzz – Activities – Homework (at the end of the session) Distractions – Try to reduce distractions when initially teaching people how to conduct an activity. – After people know how to conduct an activity, you can try to increase distractions to increase frontal lobe exercise. Break up into smaller groups to increase vocal distractions Add extraneous noise If someone messes up on buzz or ping, pang, pong make them be external distractions

130. How Often Should the Classes Be Offered? Independent Older Adults Retirement Communities Assisted Living Skilled Nursing Facilities Rehabilitation Hospitals

131. Bring college students in. Contact department chair (e.g., psychology, social sciences, health sciences, occupational therapy, sociology departments). Send them a flyer, better yet a stack of flyers to be distributed to faculty boxes Have an application and a deadline on the back of the flyer. Interview Request a two term commitment Independent study course credit might be possible

132. Summary Cognitive stimulation can delay the symptoms of dementia Cognitive stimulation programs can be done in groups using either paper/pencil or iPads Use a wide variety of activities and have a focus on executive functioning (attention, inhibition)