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Teaching Function in the Middle and/or Late Stage…. The Secret Sauce

We learn to match context with specific tasks very early on.


Alzheimer’s disease initially attacks the centers of the brain responsible for storing new memories and utilizing language.  When teaching functional activities to someone with Alzheimer’s disease, it is important to come up with ways to instruct a task that don’t rely heavily on memory or language.

We use techniques that utilize the visual cortex and the motor cortex to get the job done.. seeing and doing vs listening and executing.

But even when we use these compensatory strategies to improve comprehension and function in the home or rehab setting, there is one glaring omission from this potentially successful equation…  and that is context.

Seated at a table in the rehab gym, or in a wheelchair in the busy living room of an assisted living facility, is not the ideal location to present a toothbrush, or a picture of a toothbrush, or pantomime the use of a toothbrush to someone with Alzheimer’s disease.  Stored deep within the motor cortex and long term memory centers of the brain is a deeply ingrained movement pattern that may possibly be recruited into action in the right environment.  Most likely this person never brushed his teeth in the living room in his entire life.  Without the context of the bathroom sink, an accurate assessment of what the brain still knows is virtually impossible.

Research on the value of contextual cues in Alzheimer’s disease is sorely lacking, probably because context is difficult to achieve in research settings and nearly impossible to objectively measure.  One could postulate however, using good old common sense, that stepping up and down from a box in the rehab gym would not be as meaningful as stepping up and down an actual curb in the parking lot.   Generalization between settings does not occur in middle stage Alzheimer’s.  Context, and especially highly familiar context that is stored in the long term memory centers, is the secret sauce for successful outcomes when training any functional activity.

Take home message: Give your Alzheimer’s friends gestures and demonstration to support communication deficits, and give them context in which to perform certain motor tasks with or without an object.

Some helpful research:  This research study utilized a group of stroke patients that had impaired language and praxis.  Context (in the form of pictures) was provided to stroke patients these participants showed improvement over the control group in ADL performance.

Smania N, Girardi F, Domenicali C, Lora E, Aglioti S: The rehabilitation of limb apraxia: a study in left-brain-damaged patients. Arch Phys Med Rehabil 2000;81:379–88 70. Smania N, Aglioti SM, Girardi F, et al: Rehabilitation of limb apraxia improves daily life activities in patients with stroke. Neurology 2006;67:2050–271. 


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  1. my daughter is 3 years old and has Apraxia. We have been seineg a speech therapist (recently weekly) since she was 18 months old and she is improving slowly. I have attended a webinar with CASANA and have ordered lots of reading material. I have been thinking about homeschooling her, to avoid the teasing she will very likely face at school. I really want to connect with other parents of children with Apraxia. I am interested in your Local Parent Support Group. Although we live in Iqaluit, Nunavut we are originally from Ottawa and visit for extended periods several times a year. I would like to attend a support group meeting, if that is possible, when we next plan a visit to Ottawa. Please contact me.

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