Transcription
Cranium Crunches Workbookinstructor's manualDr. Rob Winningham &ActivityConnection.com
IntroductionTable of ContentsIntroduction1Who, What, Where, When, and Why of CognitiveStimulation Programs2How to Use the Workbooks9Suggested Curriculum20Other Features in the Cranium Crunches Workbooks26The Cranium Crunches Workbook was designed to be usedby individuals interested in maximizing their cognitive abilitiesusing the workbook’s structured program of exercises oractivities on their own or, as is the focus of this manual, bythose individuals who are part of a larger group of motivatedparticipants (e.g., in a retirement community or seniorcenter). Group-based programs have some real advantages,as participants are more accountable to attend the sessionsand be fully engaged. Also, the social interaction and supportadds meaningful benefits to one’s quality of life.This Cranium Crunches Workbook Instructor’s Manual hasbeen developed as a guide to instructors or facilitators inthe planning and implementation of the Cranium CrunchesWorkbook, which I sincerely hope you will find helpful in yourdedicated efforts to help maintain the brain health of thepopulation you serve.If you are interested in learning more about facilitating highquality cognitive stimulation programs (and demonstratingthat to residents, participants, and potential clients oremployers), consider looking into the Certified CognitiveStimulation Instructor (CCSI) Program. You can find moreinformation about the CCSI Program at the end of thisinstructor’s manual.Cranium Crunches Workbook Instructor’s Manual1
Who, What, Where, When, and Whyof Cognitive Stimulation ProgramsWho should participate?This is one of the most frequently asked (and most important)questions asked about group-based cognitive stimulationprograms. First, we should start by saying that CraniumCrunches and similar types of programs were not designed tohelp people with fairly advanced dementia. When people havedementia that has progressed to the point where they are notable to make new memories, even with a lot of practice andsupport, then doing cognitive exercise is probably not goingto help them improve their ability to make new memories.The reducing effectiveness of cognitive stimulation activitiesas cognitive impairment worsens may occur because therehas been too much brain damage or because the types ofactivities that have been shown to help are too difficult forthem to do. When people have more advanced impairments,then they often have a difficult time understanding theinstructions and staying on task.However, people who are doing fairly well from a cognitivestandpoint can benefit as well as people who are just beginningto have some cognitive problems. Based on publishedresearch and our experience with cognitive stimulationprograms, people who have mild cognitive impairment (i.e.,their memory ability is worse than it should be for their agebut not impaired enough for a dementia diagnosis) or people2Cranium Crunches Workbook Instructor’s Manualwho have early stage dementia (i.e., worsening memory,possibly to the point where living independently is becomingmore difficult) can often benefit a great deal from a cognitivestimulation program. Note that even maintaining cognitiveability should be considered an improvement if there hasbeen a long trajectory of decline.We often offer two levels of classes in a community: one thatis more challenging and one that provides more support.We have used Mini Mental State Exam (MMSE) scores toidentify the appropriate group; however, the MMSE mightnot be available to people who are not licensed to conductneuropsychological exams. People with MMSE scores of24–30 go into the more challenging class, and people whoscore 16–23 go into a class with more support and fewerparticipants. If one doesn’t have access to MMSE scores,the St. Louis University Mental Status (SLUMS) exam canalso be used. The SLUMS exam can be downloaded forfree from the Internet. SLUMS scores, like MMSE scores,range from 0–30, but the SLUMS exam is a little moredifficult. We recommend people who score 21–30 on theSLUMS be in a more challenging class and people withscores of 12–20 be in a class with more support and fewerparticipants. However, it is important to just use these teststo determine the appropriateness of a group-based cognitivestimulation class and not use it to inform people about thecognitive impairment or dementia status, as that is the workof a licensed professional (e.g., medical doctor or licensedpsychologist).Cranium Crunches Workbook Instructor’s Manual3
How often and how long?In our experience, a typical cognitive stimulation class willbe about 60 minutes long. But the time goes by fast. We willsometimes have longer classes, maybe 90 minutes long, ifthe group meets less frequently (e.g., once a week) or if theylive in the greater community and it takes longer to get to theclass than it would on a residential campus.When residents are living independently and leading busylives, then we often have classes once a week and try togive more homework. However, classes in an assisted livingcommunity can and should be more frequent, such as twiceor even three times a week. Classes in skilled nursing orrehabilitation settings can be even more frequent, possiblyfour or five days a week.How many participants?The size of the classes can vary for many reasons, but wegenerally try to have smaller classes when the participantshave more advanced cognitive impairment. For example, ifparticipants generally have mild cognitive impairment or earlystage dementia, then we might want to limit the class to 6–8participants if there is only one instructor. However, a class ofhigh-functioning independent participants can be as large as20, even with just one instructor.4Cranium Crunches Workbook Instructor’s ManualHow do I motivate participants to start and maintain acognitive stimulation program?We need to inform people about the benefits of engagingin cognitively stimulating programs and experiences. Manystudies have shown that increased cognitive stimulation aswell as cognitive exercise programs can lead to improvementsin cognitive ability, including the ability to pay attentionand make new memories. This is important for potentialparticipants to know.According to psychologists who study motivation, there aretwo main factors involved in motivation, and you can usethese ideas to help motivate your residents and participants.First, people need to believe they can do the behavior; wecall this self-efficacy. Second, people need to be awareof the benefits of doing the behavior; we call this outcomeexpectations (although I prefer to call this the “what’s-in-it-forme effect”).What’s in it for me?People usually need to know the benefits of doing somebehavior before they will be motivated to start doing it. It ispossible to increase the overall motivation of a retirementcommunity, for example, by having a series of programsdiscussing brain health research. We created a popular onehour video just for this purpose, and it can be found on theActivityConnection.com website, entitled Brain Training: Howto Maintain or Even Improve Memory Ability. The video wasCranium Crunches Workbook Instructor’s Manual5
designed to show people the benefits of cognitive exercise(as well as physical exercise, proper nutrition, and socialengagement). It is a research-based presentation, but it isdesigned to motivate a general audience by showing what’sin it for them.Another general way totap into the what’s-in-it-forme effect is to know yourresidents and potentialparticipants. You mightconsider asking them whattheir goals are or whatthey would like to improvein terms of their owncognition. Make a note ofwhat they are interestedin doing or improving andconnect that to what ispossible with a cognitivestimulation program. Forexample, they might want to be able to continue flying onplanes to see out-of-state friends or family. Then you couldpoint out that participating in a cognitive stimulation programcould lead to better concentration and abilities to navigateairports. We also know that impairments in attention makefalling more likely, so that might also factor into the goal oftraveling. If the participant seems unmotivated, it might behelpful to remind them of their goals and how the programcan help them achieve those goals.6Cranium Crunches Workbook Instructor’s ManualSelf-efficacySelf-efficacy refers to the participant’s belief that they arecapable of doing some behavior or achieving a specificoutcome. Research has repeatedly shown that people’s selfefficacy for health-promoting behaviors predicts their overallphysical activity, nutrition, and stress management. Wehave also seen self-efficacy affect engagement in cognitivestimulation programs. Fortunately, it is possible to increasesome people’s self-efficacy, which should improve theirmotivation. Here are some ways to potentially improve selfefficacy.1. Experiences in mastering new skills and overcomingobstacles will increase self-efficacy. Start participantswith a task they can complete and then the task difficultycan be increased. This is the idea behind the minisudoku puzzles in Cranium Crunches Workbooks. Ifpeople can do an easy mini-sudoku, then they mightfeel confident enough to try a 9 X 9 sudoku puzzle.2. Seeing similar people who are successfully engagingin some behavior can lead to improved motivation.Group-based programs have a huge advantage in thatthey constantly show others what is possible. It is notuncommon to tell an older adult about a new programwhere they can exercise their brains and possibly improvetheir ability to make new memories and they look at youCranium Crunches Workbook Instructor’s Manual7
and say, “Do you know how old I am?” Clearly, if they havean attitude like that, then they likely do not possess themotivation to do the work. They probably don’t think theycan do it. However, it would be somewhat nonsensical forsomeone to claim they are too old to do brain exercises ifthey are surrounded by people of the same age.3. Consider publishing a newsletter where successful classparticipants tell their story about being in the cognitivestimulation class and seeing results. Maybe include apicture of the successful participants. Seeing that person,who might be like them, can motivate someone who haslow self-efficacy.Consider bringing in additional materialsHow to Use the WorkbooksPre- and Posttest Assessments IntroductionOne of the many valuable features of Cranium CrunchesWorkbooks are the pre- and posttest assessments to bedone before and after people complete a Cranium CrunchesWorkbook. The purpose of the assessments is to measureimprovement in cognition, including attention. Doing the preand posttest assessments may help motivate people to workharder as they recognize improvement based on their level ofwork and commitment. We have also seen that when the wordgets out that participants saw actual improvements, others inthe community have been more motivated to participate inthe available cognitive stimulation programming (althoughan individual’s score should be kept confidential, unless theparticipant wants to share it with others). Word searches More sudoku puzzles iPads and other tablets to use the many apps that areavailable for cognitive stimulationHow to Administer Pre- and Posttest Assessments Guest presenters Brain health articles Ted Talks and discussions Great Courses and other lifelong education materialsYou have some flexibility in how the pre- and posttestassessments are administered. But, in general, it isrecommended that participants do all of the pretestassessments in one sitting, before they do any activities in theworkbook. Ideally, participants would have a partner to helpwith the testing, but it may be possible to do them by oneself,especially if the participant is not experiencing any cognitiveimpairment. But to maximize the validity of the assessment,8Cranium Crunches Workbook Instructor’s ManualCranium Crunches Workbook Instructor’s Manual9
we recommend that similar testing conditions are present forthe pretest and the posttest (e.g., do them in the same orderboth times, and if the participant has an assistant during thepretest, they should have an assistant for the posttest). Thelevel of distractions in the environment (e.g., people talking)can also have a significant impact on the scores.“online stopwatch”). Ideally the testing will take place in arelatively quiet and distraction-free environment. Finally, wehighly recommend that instructors and assistants try eachassessment themselves before meeting with participants toadminister them.Instructions for Assessment #1: Proper NounsBe sure to record all the scores of both the pretest andposttest assessments in the workbook. The posttests canbe completed after the entire book is complete or after theprogram is complete (e.g., a six-week, twice-a-week programthat involves cognitive stimulation, brain health education,and a possible physical exercise component).It’s important to make every effort to avoid makingparticipants feel like they are being judged when doing theassessments. Remind people that the assessments are usedonly so individuals can see improvement in themselves; theassessments are not in any way a competition nor are they amedical evaluation.Instruct participant(s) to try to fill in each blank with a man’sfirst name that begins with that letter of the alphabet. If theyget stuck on a particular letter, encourage skipping it untilthe rest of the alphabet is completed. Set the timer for twominutes. If the participant finishes all of them in less than twominutes (we don’t expect that), then document how long ittook (e.g., one minute 50 seconds). If the two-minute timergoes off before all of them are completed (that is what weexpect), count how many names were written down anddocument that number on the Assessment Score Card (seeTable of Contents for page number).What You Will Need for the AssessmentsInstructions for Assessment #2:Trail Making Exercise ExplanationYou will need timers to measure how long participantstake to complete the assessments. It is helpful if the timershave a start and stop function, such as a stopwatch. Mostsmartphones and tablets have a stopwatch function. Thereare also easy-to-use online stopwatches (simply searchThe Trail Making Exercise, initially used in 1944, has twoparts. Part A consists of encircled numbers from 1 to 25randomly spread across a sheet of paper. The object ofthe test is to connect the numbers in order, beginning with1 and ending with 25, in as little time as possible. Part B is10Cranium Crunches Workbook Instructor’s ManualCranium Crunches Workbook Instructor’s Manual11
more complex than Part A because it requires the personto connect numbers and letters in an alternating pattern(1–A–2–B–3–C, etc.) in as little time as possible. Participantsshould try to keep their pen or pencil on the paper as much aspossible. If the participant has someone helping administerthe assessment, they can quickly correct any mistakes andhave the participant draw the correct line. But it is importantto give the feedback very quickly and avoid a discussionof the mistake, as that will obviously affect the score. Also,be sure to create similar conditions when the assessmentis done, after completing the workbook (e.g., presence ofinstructor or assistant). Document time to complete the taskin the Assessment Score Card (see Table of Contents forpage number).Assessment #3: Circle C’s Exercise ExplanationThe Circle C’s assessment is a variant of a commonly usedneuropsychology tool called the Continuous PerformanceTask. The instrument was designed to measure selective andsustained attention as well as visual scanning. This simpletest will give a measure of one’s attention capacity. Thisassessment can be done alone or with an assistant.The participant needs to find all 25 C’s and circle them as fastas they can. Time needed to complete the assessment will bemeasured and recorded on the Assessment Score Card (seeTable of Contents for page number).Circle C’s KeyTrail Making KeyTrail Making Part A2117I8159222016Trail Making Part 3KFE11Cranium Crunches Workbook Instructor’s HICOOCFCRQSCranium Crunches Workbook Instructor’s Manual13
Brain MapsThe brain maps are a novel feature in the Cranium CrunchesWorkbooks that allow instructors to organize brain exerciseclasses in order to facilitate a whole brain workout. The brainmaps are also helpful in communicating to participants thebenefit of doing certain exercises, which can help motivatepeople to fully engage the program. Participants can connectthe Cranium Crunches activities with certain parts of thebrain and certain cognitive and mental abilities. For example,activities that exercise the frontal lobes will generally beexercising concentration and attention. Instructors can evenconnect the brain maps to goals that individual participantsmight establish for themselves. If a participant reports, forexample, that one of their goals is to improve their ability tomake new memories of things they need to do, then they canbe reminded that exercising their frontal lobes can improvetheir ability to concentrate, which can in turn improve theirability to make new memories.Consider reminding participants that one of the goals of agood cognitive stimulation program is to engage in a wholebrain workout, just as you might want to engage in a wholebody workout when doing a physical exercise program. Whendoing physical exercises, many people have their favoriteexercises, but those exercises become less effective atburning calories, building muscle, and increasing heart rateas the body becomes more efficient. Fitness trainers try to getpeople to vary their exercises and not just focus on one or twomuscle groups. Similarly, the Cranium Crunches Workbook14Cranium Crunches Workbook Instructor’s Manualwas designed to encourage brain exercisers to engage anduse different parts of their brains and strengthen their entirebrain, not just one region. With all that said, research hasshown that improving attention and concentration can leadto real-world improvements in the things we all need to doto stay active and independent (e.g., making new memoriesand remembering to do things in the future). This principleis important, as many brain health conscious individuals willdo a very limited set of cognitive stimulation activities. Forexample, they might say, “Oh, I don’t need to come to yourclass I play bridge” or “I am an avid reader.” While thoseare excellent activities that promote brain health, researchsuggests that improvements in cognitive and memory abilitiesrequire doing new and challenging activities, particularlyactivities that require sustained attention and concentration.The brain maps should help communicate the aboveprinciples.A participant might ask: “Why are there more CraniumCrunches that focus on the frontal lobes, as comparedto the other three lobes of the brain?”Answer: Research has shown that improving frontallobe functioning (and the ability to concentrate) canlead to improvements in a wide range of abilities andactivities, such as the ability to make new memories,the ability to remember things that one needs to do inthe future, driving abilities, and a reduction in falls.Cranium Crunches Workbook Instructor’s Manual15
Each side of our brain (left and right) has a frontal lobe, atemporal lobe, a parietal lobe, and an occipital ceTEMPORALTEMPORALLOBELOBESustained attentionProducing languageLEFTLEFTComprehending language PARIETALPARIETALLOBEPerceiving emotion inLOBElanguageAvoiding distraction16RIGHTTEMPORALLOBEGuideExecutive functioningConcentrationLEFTPARIETALLOBEMusic perceptionCraniumCrunches Workbook Instructor’s ManualLEFTLEFTTEMPORALTEMPORALLOBELOBESpatial abilitiesVisual perceptionenvironmentColor perceptionMathematical abilitiesMovement perceptionRIGHTRIGHTthings in theIntegrate sensory vigate through the LOBERIGHTTEMPORALLOBECompletingCranium Crunches ActivitiesCranium Crunches were designed to be completed bythe participant, either by keeping the pages intact in theirworkbook or tearing out the pages to work on outside of theclass. Each participant needs their own workbook. Whendoing the activities in a group, try to give participants enoughtime so most people can finish the activity. Sometimessomeone will need more time to complete an exercise andcan be encouraged to finish after class or at home. Otherswill finish much earlier than the rest ofRIGHTthe group,RIGHTso it isPARIETALrecommended the instructor have somePARIETALadditionalactivitiesLOBELOBEfor those who finish early (e.g., a word search, crossword, orother activity). At the very least, you can always give peopleRIGHT RIGHTCraniumCrunches Workbook Instructor’s ManualTEMPORALTEMPORALLOBELOBE17
a fairly long word (such as hippocampus, which is where newmemories are made in the brain) and ask the quick participantto generate as many words as they can using letters fromthe word (e.g., campus, hippo, macho, shop, hum, hip, cam,sham, pup, chip, puma, chomp). You can do this by writingthe word on the back of the sheet of paper they had beenusing.Most activities take approximately five minutes to complete,but try to adjust expectations and the timing based onthe participants and their unique needs. For example, ifparticipants seem to be getting fatigued, you might allowmore discussion rather than move on to another activity.Or, if participants are having a difficult time with an activity,you might choose to skip it. The bottom line is to be flexiblein order to maximize the effectiveness and enjoyment of aprogram, as every class and group of participants is different.Ultimately, of course, the participants need to have fun orthey will be much less likely to continue coming to the class.Other Suggestions for a Successful CognitiveStimulation Program1. Try each activity yourself prior to doing it with a group ofparticipants.2. Limit the size of the class to no more than 20 or sopeople if you are the only instructor.18Cranium Crunches Workbook Instructor’s Manual3. Stay positive, have fun, and try to not set up acompetitive atmosphere.4. Try to get volunteers to help run the classes. Volunteerscan be particularly helpful when doing pre- and posttests.Additional assistance can also be very useful when thereare participants with more severe cognitive impairmentwho just need a little support in doing the activities.5. These activities are generally not appropriate for peoplewith more advanced cognitive impairment (e.g., midstage dementia).6. Consider incorporating an educational component of theclass and bring in interesting articles or videos on brainhealth or related topics.7. Try to encourage participants to continue a program ofregular cognitive stimulation, even if the class has ended.Research has repeatedly shown that improvements inmemory and cognition are dose-dependent. In otherwords, the more cognitive stimulation one does, thegreater the memory improvements and the longer theeffects last. Research has shown that even an occasionalbooster session with 60–90 minutes of activities once amonth can allow improvements to persist over a longerperiod of time.Cranium Crunches Workbook Instructor’s Manual19
8. Remind participants that cognitive exercise is likephysical exercise, in that you can’t do it for a month ortwo and expect the benefits to persist forever.9. Take attendance and try to follow up with people whomiss class.Suggested CurriculumEvery cognitive stimulation class is different, depending onthe instructor, participants’ abilities and interests, the numberof participants in a class, the cognitive ability of participants,whether activities outside of this workbook will be used(e.g., other cognitively stimulating activities or educationalmaterials), and how much the participants want to discussrelated topics. I believe we need to be flexible in how weapproach cognitive stimulation courses. With that said, wehave tried to provide some suggested curriculums, withthe goal of engaging participants in a whole brain workout,maximizing the effects of the program, and maximizing fun.typical class can complete about eight Cranium Crunches,we have developed a suggested curriculum that is basedon the following guidelines. Please note that giving extraactivities for homework is always an option. For example,if you get through six activities and had planned to do eightactivities, then you can assign the other two activities ashomework. However, in our experience, not everyone willcomplete the homework.A typical cognitive stimulation class can include:»» 5–6 Attention, Concentration, and ExecutiveFunctioning Cranium Crunches»» 1–2 Language and/or Word Fluency Cranium Crunches»» 1 Visual Memory or Social/Humor Cranium CrunchesIf you are able to get through eight activities each class, thenthe Cranium Crunches Workbook will take approximately 12class meetings to complete.Most cognitive stimulation classes meet for about onehour. A typical one-hour class can complete approximatelyeight Cranium Crunches, although that number can vary.For example, if the instructor allows a little discussion orpresents educational information about brain health, thenthat number might go down. It is fine if you don’t get througheight activities each class. But with the assumption that a20Cranium Crunches Workbook Instructor’s ManualCranium Crunches Workbook Instructor’s Manual21
Suggested 12-Day CurriculumDay 11. Trail Making2. Letter Symbol3. Dot-to-Dot4. Mini Sudokus5. Split Words6. Proper Nouns7. Mental and Shape Rotation8. Cartoon CaptionsDay 21. Trail Making2. Alphabet Code3. Process of Elimination4. Anagrams5. Mini Sudokus6. Verb Generation7. Word Search8. Mental and Shape Rotation9. Cartoon CaptionsDay 31. Trail Making2. Dot-to-Dot3. Process of Elimination4. Anagrams5. Junk Drawer6. Split Words7. Proper Nouns8. Word Search22Cranium Crunches Workbook Instructor’s ManualDay 41. Alphabet Code2. Trail Making3. Letter Symbol4. Anagrams5. Mini Sudokus6. Split Words7. State Exercise8. Word SearchDay 51. Alphabet Code2. Dot-to-Dot3. Anagrams4. Mini Sudokus5. Junk Drawer6. Proper Nouns7. Word Search8. Mental and Shape Rotation9. Cartoon CaptionsDay 61. Trail Making2. Process of Elimination3. Anagrams4. Mini Sudokus5. Junk Drawer6. Split Words7. Verb Generation8. Word SearchCranium Crunches Workbook Instructor’s Manual23
Day 71. Trail Making2. Dot-to-Dot3. Process of Elimination4. Anagrams5. Split Words6. Rhyming7. Word Search8. Mental and Shape RotationDay 81. Alphabet Code2. Dot-to-Dot3. Anagrams4. Mini Sudokus5. Junk Drawer6. Proper Nouns7. Word Search8. Mental and Shape Rotation9. Cartoon CaptionsDay 91. Trail Making2. Letter Symbol3. Process of Elimination4. Anagrams5. Split Words6. Link Letters7. Verb Generation8. Word Search24Cranium Crunches Workbook Instructor’s ManualDay 101. Trail Making2. Alphabet Code3. Anagrams4. Mini Sudokus5. Junk Drawer6. Split Words7. Rhyming8. Word Search9. Cartoon CaptionsDay 111. Trail Making2. Dot-to-Dot3. Process of Elimination4. Anagrams5. Mini Sudokus6. Proper Nouns7. Word Search8. Mental and Shape RotationDay 121. Trail Making2. Alphabet Code3. Process of Elimination4. Anagrams5. Split Words6. State Exercise7. Right on Target8. Cartoon CaptionsCranium Crunches Workbook Instructor’s Manual25
Other Features in theCranium Crunches WorkbooksWe have tried to answer common questions that participantsask in the Frequently Asked Questions section of eachworkbook. We encourage you to review this informationbefore beginning a class.1. I am concerned about memory loss, as I sometimeshave difficulty doing these activities. Should I beconcerned?These activities get easier over time, and we don’t expectperfect performance. We exercise mental abilities that arechallenging, and we have created the Cranium Crunchesto target key cognitive abilities and regions of the brain.Please keep in mind that the harder you work, the greater thegains. As with physical fitness programs, we often need todo exercises that are difficult (at first) in order to improve ouroverall physical fitness. The same is true for the brain. But ifyou are or someone you know is concerned about memoryissues, it is important to visit a doctor or other healthcareprofessional. Some causes of dementia-like symptoms arereversible, and it might be important to get a good medicalevaluation.2. I am trying to keep track of the number of cognitivelystimulating activities I engage in each day and week. How26Cranium Crunches Workbook Instructor’s Manualdo I know whether an activity is cognitively stimulating?For example, I play bridge each week—does that count?An activity is usually considered cognitively stimulating ifyou cannot successfully do the activity while thinking aboutsomething else. For example, if you cannot think about ameal you are planning for the next day while successfullyplaying bridge, then bridge is a cognitively stimulatingactivity. However, if you can daydream while driving along afamiliar route, then driving along that route is not cognitivelystimulating. On the other hand, it might be cognitivelystimulating to drive in an unfamiliar city while trying to find aparticular address, as most people cannot do that successfullywhile simultaneously daydreaming.3. How often should I do these Cranium Crunches? Whencan I stop doing them?Doing brain exercises is a lot like doing physical exercises.The more you do them, the better they work. The more youchallenge yourself with difficult exercises, the better theoutcomes. And, just like physical exercise, brain exerciseneeds to be done continually
who have early stage dementia (i.e., worsening memory, possibly to the point where living independently is becoming more difficult) can often benefit a great deal from a cognitive stimulation program. Note that even maintaining cognitive ability should be considered an improvement if there has been a long trajectory of decline.
