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Goals and Motivation

Mrs. ML was admitted to a long-term care clinical facility to readjust the therapeutic intervention and control the Parkinson’s disease symptoms. At time of admission, she was also presenting depressive symptoms, with suicidal ideation and behavioral changes (verbal aggressiveness, impulsiveness, and disinhibition). She was not fully aware of her condition, but felt that “something was wrong with her.”

Comprehensive neuropsychological testing was performed and revealed deficits in attention, learning and memory (encoding and retrieval), executive functions, and slowness processing speed. In this evaluation, it was also noted that she had no control over her own medication and there were relevant changes in the sleep-wake cycle.


Having assured optimal pharmacological monitoring after multidisciplinary discussions (including not only general medicine, but neurology and psychiatry consultancy), an integrative non-pharmacological intervention was implemented. The team included a neurologist, a psychiatrist, a neuropsychologist, a nurse, an occupational therapist, and a physiotherapist, who actively participated in the design and implementation of the program. This was adjusted over time, considering the presence and severity of the symptoms and the overall needs of Mrs. ML:

  • 1. Behavior-oriented approaches were adopted to manage behavioral changes, including sleep disturbances:
    • Establishing routines
    • Decreasing stimulation after sunset
    • Avoiding caffeine intake after lunch
    • Staff training improving communication skills and routine implementation

The major characteristic of her clinical state was that it fluctuated a lot between 1 day to another or even frequently on the same day. When Parkinson symptoms worsened, cognition, emotion, and behavior declined at the same time. She became more disoriented and confused, irritable, socially inappropriate, impulsive, and obsessive. The respect of the routines and adequate communication patterns helped the team manage these periods. She needed clear and short messages and a more discrete supervision, allowing her to maintain a sense of self-control on the environment.

2. Emotion-oriented approaches were adopted to manage depressive symptoms,

including suicidal ideation:

  • Reminiscence of meaningful life events, personal beliefs, values, and expectations
  • Validation of feelings and emotions and thoughts as an individual uniqueness

One way of dealing with her pain and doubts was writing about them. She questioned the sense of living with this disease because she only could expect more pain and the progression of the symptoms, without the hope of a cure. She felt she was losing her identity and spoke of death as a way out. It was important for her to revisit her past, in particular some events of her life. She remembered her academic career and achievements without effort, her travels and visits to “the most famous museums around the world.” Using personal photographs, books, and even virtual tours to relevant places and cities helped her recover those memories, to talk and to give her a sense of what she was feeling. Sometimes, while “revisiting” museums, she walked through all those corridors and rooms several times, looking for new perspectives of the same works that delighted her. This gave her a sense of keeping her identity, and she was happy to find herself in those meaningful reminiscences. The team validated her feelings and tried to help her look to her past and present as a continuum yet to be filled.

  • 3. Cognitive-oriented and sensory stimulation-oriented approaches:
    • Group sessions for cognitive stimulation that included reality orientation therapy and other sensory and motor activities
    • Individual sessions of cognitive rehabilitation, including cognitive training tasks

Initially, it was not easy to find significant and pleasant activities for Mrs. ML, because she thought every task is too easy and boring, even if she had some difficulties doing those tasks. During the morning, she spent some time in a group with other patients, doing different activities in a generalized cognitive stimulation perspective. They started with formal activities of reality orientation therapy, such as updating the calendar, reading, and discussing the main news of the day. After that, they played word or board games, were involved in art activities, had conversations on different topics, or prepared the celebration of a particular festivity. When she felt better, she enjoyed joining the group, providing her special touch to some of the activities and spending some time with other patients to whom she started to be closer. When she felt worse, she preferred being left alone or having individual sessions.

At the same time, she had individual cognitive rehabilitation sessions during which she performed cognitive training tasks in order to strengthen her most affected cognitive functions. During these sessions, she made paper and pencil exercises and trained focused and sustained attention (e.g., cancelation tasks), verbal memory (e.g., recall a newspaper article) and learning (e.g., recall a word list previously learned), and capabilities of mental flexibility, planning, self-monitoring, and sensitivity to interference. She felt that these tasks gave her a sense of challenge that she enjoyed.

After some time, the staff started to look for activities that she could do with help but also alone, especially during the periods without therapies. She agreed to build a puzzle with a photograph of a countryside landscape, but saying that she had never done a puzzle before. Initially, this activity was just to pass the time, but some weeks later, it had become the focus of her neuropsychological rehabilitation program. Soon a structured strategy was developed, based on different steps in approaching the puzzle. This included starting to look to the puzzle as a whole and explore its colors, images, possible meaning(s). Then the separation between contour and content pieces in two boxes was proposed, starting with the contour. After that, pieces were separated according to their colors, shapes, or images.

In this context, building a puzzle fulfilled a variety of objectives such as involvement in a leisure activity, significant for the patient and that helped in the way she look at her own personal story, built based on the dimensions of self-pleasure, selfvalues, and a causal self-agent in relationship with the world. The puzzle acted as a motivational catalyst for the therapeutic process, becoming a cognitive technique. Looking at the puzzle as a whole and from this to its parts required a high level of attention, concentration, and visual discrimination of color and forms. Deciding where to start, planning the different stages, and implementing them mimicked what she was asked to do daily. Through a puzzle, fine motorskills were also reached, as the need to test and choose the movements allowed her to improve her skills. Catching, fitting, removing, rotating, persisting, or even giving up gave her a sense of control over the progression of the disease and over her present reality. In her own words, she mentioned “building a puzzle is like giving an order to my chaotic universe"

Over time she kept a higher interest in knowing and understanding her disease and its progression, questioning the etiology, therapeutic interventions, and her role in all of that. She read a lot of books about Parkinson’s disease and dementia and asked important questions to different members of the team. Mrs. ML’s active role was even a challenge for the staff who tried to always respond to her most complex questions and doubts.

At present, she has significant cognitive deficits and a severe psychomotor retardation. Her spontaneous speech is fluent, with anomic pauses and slowness. She no longer writes but she is able, for periods, to express complexfeelings and her expectations about the future.

The case of Mrs. ML is also an example of the importance of an adequate technical training in non-pharmacological interventions, in order to enable the use of an apparently leisure activity like building a puzzle into a therapeutic strategy.

In summary:

  • 1. This is a challenging situation, which involves cognitive and emotional issues. Neuropsychiatric and psychological symptoms appeared in the context of BPSD, progressive motor limitations, and cognitive impairment (due to Parkinson’s disease).
  • 2. This case is an example thatpharmacological interventions are necessary but not always sufficient.
  • 3. In working with Mrs. ML, it became clear that strictly cognition-focused or emotion-focused interventions would not target her personal complex issues altogether. Cognition-focused approaches may and in fact should be emotionally informed.
  • 4. With this case, we also tried to highlight the importance of teamwork on the implementation of multidisciplinary approaches.
  • 5. However, it is not always possible to provide integrated multicomponent interventions.

Finally, the main message is that something can always be done during the entire process of the disease.

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