Recent research has shown us that many factors affect our cognitive abilities and chance of developing dementia in older adulthood. It is important to understand these factors and possible causal mechanisms in order to develop interventions, suggest lifestyle changes, and consider the etiology of cognitive impairment.

Most people have heard of the Use It Or Lose It Theory, but that idea is rarely discussed in the scientific literature. In this chapter, we will discuss a compatible idea known as the Reserve Hypothesis. The Reserve Hypothesis is a superior idea because it provides an explanation for data supporting Use It Or Lose It. These are important concepts as they help provide a foundation to understand the basis of cognitive rehabilitation and the etiology and course of most types of cognitive impairment.

Recent research has shown that while the incidence of dementia is increasing in Western Europe and North America, the prevalence is actually plummeting. Appreciating these ideas and their causes leads to a much more nuanced understanding of the underlying causes of dementia and interventions that could decrease symptoms of cognitive impairment.

An understanding of how executive functioning affects cognitive abilities and mobility. Controlling unwanted behaviors is critical, especially for people who work with cognitively impaired individuals. We will discuss executive functioning so therapists and other professionals can maximize the efficacy of therapeutic outcomes.

In order to understand why we sometimes fail to make new memories, we must explore how we successfully make them. A classic memory study that launched modern memory research and understanding will be explored in an effort to build foundational knowledge that can be used to customize interventions. Making new memories requires rehearsal and attention, requirements that can be targeted.

It is easy to overwhelm clients’ working memory, especially if they are experiencing cognitive impairment. It is important to understand the limits of working memory and other cognitive resources, in an effort to maximize therapeutic outcomes. We will explore how instructions and feedback need to be altered when working with cognitively impaired individuals.

The three memory processes are explored, as all memory failures are a failure of one of those processes. First, we encode new memories. Second, we store them over time. Third, we retrieve previously encoded memories. Any memory failure is a failure of one those three processes. Being aware of the above not only help us understand why memory failures might be occurring but also suggest possible intervention approaches.

There are three types of memories and two classes of memories. It is important to understand how these types and classes of memories are affected by dementia and cognitive impairment. Choosing the best intervention often requires knowledge a client’s ability to make each of these types of memories.

One of the three types of memories, procedural memory, can be made in most clients who have dementia. Often this ability is the only way to help more cognitively impaired clients learn new behaviors and compensatory strategies. Thus, the possibilities and limitations of making new procedural memories, including looking at a client’s approach to tasks and assessing their sequencing in Activities of Daily Living, will be examined.

The idea that encoding new memories is based on rehearsal is not complete. In order to maximize cognitive ability, executive functioning in general and attention in particular must be maximized. The importance of these principles is demonstrated, and strategies are introduced that therapists and other professionals can use to maximize attention, in the moment, even without long-term cognitive rehabilitation. Common challenges experienced when people lose inhibitory abilities are also discussed.

Testing clients has a number of positive benefits, including focusing clients on the to-be-remembered information and giving them rehearsal trials. We will discuss how to take advantage of retention testing, in an effort to help people make new declarative memories and learn new compensatory strategies.

Another empirically supported strategy to enhance executive functioning and attention is the Generation Effect. The Generation Effect refers to an enhanced ability to remember ideas, information, or compensatory strategies that one actively figured out versus having the information passively presented. Visualization and the use of signs are also explained in this chapter.

Caregivers can either impede therapeutic progress by doing things for their clients that the clients are able to do, or caregivers might impede learning by supporting behaviors in a different sequence than the therapist was trying to do. Clients can get additional rehearsal trials by explaining to their caregivers how they need to perform a certain task. We will discuss how a quick conversation with a caregiver can improve therapeutic outcomes.

An important goal of cognitive rehabilitation is to achieve benefits that generalize or transfer beyond the trained task. We will discuss what works, what doesn’t work, and why. Cognitive rehabilitation dosing recommendations and ideas to maximize therapeutic outcomes are also examined.

In an attempt to maximize therapeutic outcomes, we will discuss who can assist in delivering cognitive stimulation interventions, who can benefit from those interventions, how much to do in a session, and difference in delivery modalities based on the environment.

We will explore a wide range of cognitive rehabilitation exercises designed to exercise executive functioning. Interventions designed to exercise selective attention, sustained attention, inhibition, and theory of mind are explained.

A wide range of cognitive rehabilitation materials designed to exercise spatial and language abilities are presented in this chapter. Mental rotation, expressive language interventions, word finding, and inhibition of language abilities are discussed.

We will discuss options for individual and group cognitive rehabilitation. Using caregivers and volunteers in various rehabilitation settings is also discussed. In addition, home exercise interventions will be explored. Options for using tablets and computers to deliver cognitive rehabilitation programs are considered. Many available options will be explored. Some of the available products have the advantage of adjusting difficulty level, based on recent or previous performance.

It is a myth that all older adults are at increased risk of depression. Risk factors for geriatric depression and common treatment options are explored in this chapter, along with the effects of depression on cognitive abilities.

Motivation is highly correlated with ultimate therapeutic outcomes. We will explore one of the most useful theories of motivation and introduce how therapists and other professionals can use it to develop short-term motivation strategies that help to improve clients’ beliefs that they can do the necessary work. The idea that clients need to be aware of the benefits of doing specific therapeutic exercises is introduced. One of the best predictors of a client’s success is their self-efficacy, or their belief that they can do something and attain a desired outcome. We will discuss the concept of self-efficacy and ways to improve a client’s self-efficacy for therapy.

Whether or not someone is willing to do some behavior is, in part, determined by their knowledge of the benefits of doing that behavior. We will discuss how to connect the therapy exercises to functional goals and outcomes that the client wants. Strategies for how therapists and other professionals can better explain why exercises are being prescribed are provided. There are other tools that professionals can use to maximize motivation. They can point out the consequences for not engaging in therapy. Practitioners can also benefit from asking clients to report the frequency and duration of home exercises. Caregivers can also be used to maximize motivation and therapeutic outcomes.

Unfortunately, people with dementia and traumatic brain injuries often engage in behaviors that can negatively affect their quality of life. Caregivers and staff members are often unsure how to handle unwanted and challenging behaviors. In this chapter, we will look at how executive functioning mediates behavior and use that to develop intervention strategies so people can better inhibit unwanted behavior.

Often times people with more advanced cognitive impairment will be living in the past and have even lost more recent memories. We will discuss these phenomena and how this process usually abides by the principles of retrogenesis. We will then discuss interventions designed to redirect attention by taking advantage of what the person remembers and comprehends. The goal will be to reduce unwanted behavior and the need for pharmaceutical interventions.