Cognitive function in people with Parkinson’s disease

Developing occupational therapy cognitive interventions

by Stephanie Stemmler  •  September 15, 2020

Left to right: Erin Foster, PhD, OTD, OTR/L, administers a pre-treatment assessment, the NIH Toolbox, to Charles.

In his home outside of St. Louis, a 65-year-old resident is working on memory and executive function skills – figuring out ways to keep track of information, create and check off items on his ‘to-do’ list and, in general, stay mentally, socially and physically active while dealing with a diagnosis of Parkinson’s disease.

The resident, Charles, is part of a new cognitive strategy intervention study led by Erin Foster, PhD, OTD, OTR/L, an assistant professor of occupational therapy, neurology and psychiatry in Washington University School of Medicine’s Program in Occupational Therapy. The study is an extension of research Foster has done for more than a decade focused on cognitive functioning in people with Parkinson’s disease. “Parkinson’s disease is considered to be more of a movement disorder than a cognitive disorder by many clinicians and, as such, rehabilitation has focused on physical or motor impairments,” Foster says. “There are, however, many cognitive issues at play that should be key factors when determining which rehabilitative strategies are going to be effective for people with this disease.”

As an occupational therapist, Foster’s research specifically addresses functional cognition. At its core, functional cognition is the intersection of cognitive skills and the performance of daily life tasks. More than asking if a person can dress themselves or eat, Foster’s interest in functional cognition focuses on higher-level, more complex activities, such as whether an individual can manage finances, initiate and engage in ongoing conversations, successfully manage their own medications, or plan a grocery shopping list, get the items and then prepare a meal.

In her early research efforts, published in the American Journal of Occupational Therapy and the Occupational Therapy Journal of Research beginning in 2011, Foster identified a strong link between cognition, namely executive function, and daily life function in individuals with Parkinson’s disease. More significantly, the functional cognitive deficits appeared before motor disabilities were noted.

“In controlled studies in our performance laboratory, we have found that cognitive dysfunction is associated with poorer performance of daily living skills and reduced participation in instrumental, leisure and social activities,” says Foster. “We actually found that problems with executive functioning in the early stages of Parkinson’s disease are more disabling than motor dysfunction.”

Foster heads the Cognitive and Occupational Performance Laboratory in the Program in Occupational Therapy, where she is now working with PhD, OTD and MSOT students to better understand and develop rehabilitation interventions to address functional cognition. With funding from the American Occupational Therapy Foundation and National Institutes of Health (R21 grant), she and her team have developed an occupational therapy intervention that they are testing in clients with Parkinson’s disease. The intervention is an adaptation of the Multicontext Treatment Approach initially developed by Joan Toglia, PhD, OTR/L, FAOTA, at Weill Cornell Medical College. Toglia is a co-collaborator in Foster’s study.

“We piloted the occupational therapy cognitive intervention within a very small group to see if people with Parkinson’s disease can engage in it and might have positive outcomes,” Foster says. “The results were promising, with everyone enrolled in the study documenting clinically meaningful improvements in their functional cognition as well as reporting high satisfaction and enjoyment with the treatment. We now have taken it a step further with a randomized controlled trial. We trained two clinical practice occupational therapists and are evaluating whether the intervention can be administered consistently in the clinical setting over time and whether it is beneficial for people with Parkinson’s.”

Charles, who was diagnosed with Parkinson’s in 2019, is among those involved in the study. Results should be available in the next year or two. “Our intervention uses a guided learning approach to increase people’s awareness of their functional cognitive performance and then guide them so that they can generate their own strategies to successfully work around a particular deficit and accomplish their goals,” explains Foster.

In addition to this ongoing study, Foster and the students she mentors are working with the local chapter of the American Parkinson Disease Association (APDA). There, student-led studies evaluating the effects of cognitive stimulation therapy and improvisational dance are under way. Originally conducted in person, those studies have temporarily gone virtual via video-conferencing as a result of the COVID-19 pandemic.

Foster originally majored in biology and psychology before turning her attention to occupational therapy, where she recognized that she wanted to focus on research related to cognition and neurological disorders. In addition to the Program in Occupational Therapy, her lab is affiliated with the Movement Disorders Center within Washington University’s Department of Neurology.

“We need to continue to advocate for the non-motor needs of people with Parkinson’s disease,” she emphasizes. “More than 60,000 Americans are diagnosed with Parkinson’s each year, and by 2030, the Parkinson’s Foundation estimates that 1.2 million Americans will be living with the disease. Awareness is growing among clinicians for the need for cognitive interventions to treat Parkinson’s, but that awareness should be higher. My hope is that my research will help to raise that awareness and will provide evidence-based and effective cognitive treatment options for people with Parkinson’s.”

Foster was awarded an R01 grant from the National Institutes of Health (R01AG065214) for a new collaborative research effort involving the Washington University Movement Disorders Center and the Department of Psychological & Brain Sciences, which focuses on underlying mechanisms and interventions to enhance prospective memory in people with Parkinson’s. This study couples a cognitive strategy intervention with neuroimaging to better understand and improve prospective memory in this population and to determine whether there are specific biological or other predictors of interventional treatment response.