Editor’s Pick | Free to All – Cognitive Rehabilitation Therapy: Should it be provided for people diagnosed with dementia?

Pool J, Marshall E (2025) Cognitive Rehabilitation therapy Should it be provided for people diagnosed with dementia? Journal of Dementia Care 33(4) 32-36.

GREAT Cognitive Rehabilitation therapy has been shown to be effective in addressing lost abilities. Jackie Pool and Emma Marshall (left to right below) describe how it was used effectively to help an individual and his family, and recommend that this therapy should be offered as a post-diagnostic service.

Traditional dementia care has focused on a model of passive care which, even when at its most person-centred, is likely to be disabling and disempowering as carers tend to compensate for the person’s difficulties by stepping in to do the things the person is struggling with.  Evidence now requires us to disrupt this outdated model which, whilst well-intended, may be viewed as acting against the disability rights of individuals who are living with dementia.

This is the story of Jim and his daughter Jenny. Their names have been changed to protect their anonymity but their story is real and true. It begins with an interview with them about their post-diagnostic experience following Jim’s diagnosis of dementia from his GP in July 2024. This followed a gradual decline in his ability to find words which impacted on his participation in conversations and on his emotional well-being. 

JP: What were your expectations of treatment and support when you received the diagnosis?

Jenny: I expected that a specialist would explain the diagnosis – as with any other condition – and explain what support and treatment options there were for us. Instead the Memory Team communicated the diagnosis to the GP who then communicated it to us. We heard that medication was not appropriate, but nothing else was offered except support groups for people with dementia and their carers. 

Jackie Pool is an Advanced GREAT CR Practitioner, retired occupational therapist and Campaigner for Occupational Justice for people living with dementia

Emma Marshall, is Specialist Neurological Occupational Therapist working for Peartree Community Services.

Summary

This article describes the use of a cognitive rehabilitation therapy programme to address lost abilities of a person diagnosed with dementia. It demonstrates how it is possible to learn from an accessible e-learning course to deliver the personalised programme in a few sessions in order to support an individual to improve in function and in well-being. The programme is evidence-based and the course and tools are free to access.
In this article, the journey from being diagnosed to benefiting from the cognitive rehabilitation programme is related by the family and illustrates how difficult it can be for individuals to currently receive enabling support. It suggests that GREAT Cognitive Rehabilitation therapy should be available and accessible via statutory services to all people who are living with dementia.

I had hoped for something which would help keep my dad as well as possible for as long as possible, managing independently as much as he could and helping us build on strengths. I also wanted something which would educate us in how to support my dad, maybe correct some ‘wrong’ attitudes which can imply blame or end up putting energy in to things which are not helpful.

JP: Were you provided with any information about how you could address the difficulty in doing things caused by the memory problems?

Jenny: No nothing like this was offered. I asked about cognitive support and later received a leaflet about CST (Cognitive Stimulation Therapy). At that point we made a self-referral, but we have never heard back.

So, I went online and also began talking to people. Someone sent me a link to the Exeter University GREAT CR therapy work and from there I found the Alzheimer’s Society Living Well guide. At that stage my dad was so pleased to read something that helped him understand that he was not so isolated, that this was an illness not a failure. I looked up GREAT CR therapy and searched ‘rehabilitation’ to find different providers. Peartree came up in the search and I saw that they did some work with people experiencing dementia. I phoned up one Friday afternoon and spoke with the manager who did not know about, but was so interested in, the GREAT CR therapy work that I became much more hopeful. 
I also contacted Jackie Pool via a friend she had supported when her mum had dementia. Jackie offered to remotely support the Peartree OT and also provided us with the link to the free GREAT CR therapy e-learning course, which the OTs at Peartree completed.

JP: How did you feel about paying Peartree for the service they provided?

Jenny: I was happy that I had Peartree who would be able to do the work, however I found it very difficult to persuade my parents that this was something good that could really help us but which was not available on the NHS. It would have been easier if the GP had been familiar with the approach and could have recommended us to go to Peartree, but instead it was my suggestion with no one else to say this is good.

JP. What were you expecting from the Peartree service?

Jenny: I wanted someone to come to visit my parents at home and introduce us to the concepts and work with us long enough for us to be able to apply the principles in other situations. I expected excellent engagement with my dad as an individual, getting to know him and seeing what he could do as well as what is more difficult for him. I expected the therapist to build rapport with my mum so that she felt confident to ask questions and support my dad with the techniques. I wanted feedback to me so that I could support the whole process and encourage my parents.

Focus on rehabilitation

Rehabilitation-focused care is proactive and enabling: identifying the impairments that cause functional difficulties and either repairing the damage, compensating for the damage, or restoring function. Repairing the damage to neurons that is causing a cognitive impairment is currently not possible but, by bypassing the damaged areas and utilising intact faculties it is possible for the person to learn a new way of achieving their functional goal. So although actual physiological repair is not possible, cognitive rehabilitation approaches can restore lost abilities.

GREAT Cognitive Rehabilitation (CR) was first used as a title for the research study into the specific therapy programme that was developed by the University of Exeter research team and published in 2019. The acronym GREAT stands for Goal oriented cognitive Rehabilitation for Early-stage Alzheimers (and related dementias) Trial. The therapy programme itself is now referred to as GREAT Cognitive Rehabilitation or GREAT CR, and those who have completed the course and are delivering the GREAT CR therapy programme are known as GREAT CR practitioners.

Key Points
  • It is possible for people diagnosed with dementia to learn new skills and information or to relearn lost skills and information
  • GREAT Cognitive Rehabilitation therapy is an individualised, one-to-one programme of six sessions of 1 hour per week
  • There is a free e-learning course to enable professionals and care givers to become GREAT Cognitive Rehabilitation practitioners
  • GREAT CR therapy should begin with a SMART goal that is meaningful and important to the individual
  • SMART goals support practitioners to plan the enhanced learning techniques that will enable the goal attainment
  • SMART goals support the individual’s and their care partners’ motivation to participate in the programme through measurement of their progress
  • Involvement by family or other care partners in the programme helps to embed and maintain the individual’s progress
  • GREAT Cognitive Rehabilitation therapy should be provided as a post-diagnostic service
GREAT CR therapy

GREAT Cognitive Rehabilitation (GREAT CR) therapy is a personalised intervention that supports functional ability through a one-to-one programme of around six sessions with a trained practitioner. It helps people with mild to moderate dementia to maintain their independence by more effectively managing the impact of dementia on their ability to engage in everyday activities. There are two types of cognitive rehabilitation: restorative treatment and compensatory treatment. Restorative treatment involves using enhanced learning techniques and practising skills to improve them, while compensatory treatment involves learning how to work around deficits or injuries.

Jim’s difficulties

Following Jim’s diagnosis in July 2024, he felt that his word-finding difficulties had deteriorated leading to him withdrawing and being anxious in social settings and when meeting new people. He was also struggling to join in the weekly family video calls.

Jim: “I don’t want to be remembered like this, I feel useless… have lost my identity. I find conversation challenging to follow and have difficulty finding relevant words and topics. I also struggle with names and remembering what has happened, I forget to take my medication too. I have tried making notes to remember things but I even forget to make the notes.”

Jim explained to Emma that that being able to recall what he has done during the day is really important to him as a step towards being able to talk about this with his family. He had found communication with his family increasingly challenging, causing him to feel very low in mood and isolated. Jim described that he felt that one of the main barriers to communicating with friends and family was around not being able to freely think of or recall recent events and come up with conversation or things to say.

Emma noted when she visited that Jim had multiple note pads that he tends to misplace. Through her initial occupational therapy assessment it became clear that the main areas of cognitive difficulty hindering functional participation and performance were around information recall and word retrieval.

Emma supported Jim to set two SMART goals (Specific, Measurable, Achievable, Relevant, Time specific) to address the medication difficulty and his word/topic finding conversational difficulties.

Goal One: I will take my medication every morning with my cup of tea.

Goal Two: Every day at dinner time I will write down, on the correct date in my diary, three things that I have done that day and then say them out loud without referring to what I have written.

Identifying needs and formulating goals with the person with dementia is central to the cognitive rehabilitation process. Working with the person to help them to identify what is important to them ensures that the intervention will be personalised and meaningful to the individual. In addition, having a specific therapy goal provides a positive focus for the person, their care supporters and  their cognitive rehabilitation  practitioner. This ‘SMART goal’ approach ensures that the intervention is measurable as the practitioner can break the goal down into smaller components in order to use a graded approach to achieving the whole goal. In turn, this enables the person and their care supporters to identify and celebrate progress, and this in itself is motivating. The grading of the goal activity also supports the practitioner in their clinical reasoning about which cognitive rehabilitation strategy and approach to use.

The BGSI-S (Clare et al 2020) was used to record each goal as the full (100%) achievement and then each goal was broken down into achievable steps which also supported the measurement of the level of goal attainment towards the full achievement. This helped Jim to see the result of his hard work towards the goal and the progress he was making, which was highly motivating and impacted on his self-esteem.

Emma, Jim and his wife worked together to create a cognitive rehabilitation plan of strategies and techniques that would help him to address his goals. These needed to not only address his cognitive difficulties but also fit with their lifestyle.  

Impact on relationships — and sense of self

Consideration needs to be given to the impact of the dementia on the relationship between the person and their family and social network and also on their own sense of self. The stigma of dementia in society and the dehumanising belief that the person is no longer ‘themselves’ can impact on the belief that improvement is possible and therefore on engagement in a rehabilitation programme.

Alternatively, over-enthusiasm in the process can lead
to unrealistic goals, and the practitioner must provide guidance here. Likewise, if the person or their care supporters do not allow rest time in between the rehabilitation practice, the person will become exhausted and so the practitioner must also give guidance on pacing the rehabilitation practice.

Goal One

A combination of compensatory and enhanced learning strategies were used for Jim’s medication goal: 

I will take my medication every morning with my cup of tea.

Compensatory strategies:
  • The dosette box acted as a memory aid to support Jim to recognise whether he had taken the medication, this worked well for Jim as he was generally well orientated to the da
  • Moving the dosette box from the busier kitchen environment to Jim’s bedside table made it more noticeable. This also worked well in terms of the task association – taking the tablet with the cup of tea which Jim places on his bedside table to have in bed every morning.
Enhanced learning strategies:
  • Action-based learning – Jim was the person who carried the dosette box upstairs and placed it on the bedside table.
  • Expanding rehearsal – Practised “going through the motions” from the kitchen where Jim makes his morning cup of tea, to upstairs where he would put his cup of tea on the bedside table next to the dosette box and then open the correct day. Repeating this process every day to support habit formation.
  • Prompting – Jim’s wife provided verbal prompts as needed, initially these were more direct and then gradually faded.

100% goal attainment was reached over the course of six sessions.

Goal Two

Enhanced Learning strategies were used for Jim’s second goal of being able to recall the day’s events as topics of conversation with his family: 

Every day at dinner time I will write down, on the correct date in my diary, three things I have done that day, and then say them out loud without referring to what I have written.

In order to do this, there needed to be some initial preparation, and Jenny supported her parents to obtain a page per day diary that was always be kept in the same place and in the location where the task was to be carried out. They agreed that the best time of day was after dinner and so the diary was kept on the dining room table. They decided to use a diary elastic to bookmark the correct page and Jim elected to use his daily newspaper to double-check that he was writing on the correct page. 

The potential of GREAT CR: Emma’s comments

Carrying out GREAT CR therapy with a client has shown how rehabilitation has a valuable role within dementia care, it is not just about compensatory strategies. I have seen how, through the enhanced learning strategies, there has been an improvement in Jim’s cognitive functioning in the areas of information recall and word retrieval.

Having a friend/family member/carer to support intervention is vital for carry over and goal achievement. In situations where the care partner may have challenges themselves (for example their own cognitive difficulties or age related changes, difficulties around fatigue or difficulties coping) it is important to look at what extra support can be utilized. In this situation, Jim’s daughter was a key support.

GREAT-CR therapy provides a good framework for education when talking about strategies; this then also adds to motivation and engagement. For example, with Jim, the use of expanding rehearsal to recall written information at increasing time intervals and mnemonic/semantic/multimodal elaboration techniques to encourage information retrieval led to discussion on the importance of continuing to work on and challenge memory.

We then linked this to the neuroplasticity principle of “if you don’t use it you’ll lose it” and how it is important to train the brain as you would the body. Through practising and explaining the techniques and linking them to real life meaningful functional tasks, people can then start to see how these could be transferable in other situations and also how other tasks can be beneficial from a rehabilitation perspective. For example Jim’s

wife asked if the idea of expanding rehearsal and prompts as used with the diary goal could be used after watching a TV programme or reading the paper together as a way of “exercising the brain”.

Implementing techniques can be challenging if someone is “set in their ways”. For example, initially Jim was not keen on keeping his dosette box on his bedside table as his medication had always been kept in the kitchen. Education provided a helpful way of overcoming this, through reminding Jim of the rationale behind placing the dosette box on the bedside table – to link the task of taking medication with a routine task that happens every day when he would be wanting to take his medication i.e. morning cup of tea, which he places on his bedside table and has in bed. This led to a good discussion around memory strategies and the benefit of linking a new task with a routine task to form a habit, and the benefits of getting into a good routine with consistent medication taking now while he is only on one tablet in case more are added in the future.

It is really important to not overload or overwhelm with too many goals at once. The active involvement of Jim’s daughter was key in supporting carryover between sessions and overall goal achievement. In future cases, where there is a lack of care partner support, involving rehabilitation assistants (RAs) to help bridge this gap would be important to consider and highlights a potential training need within our service. Depending on individual cases, the use of RAs could also help reduce cost and increase accessibility of intervention for clients, with sessions being a mix of occupational therapy and rehabilitation assistants.

Enhanced Learning Strategies:
  • Action based learning – Emma wrote three prompt questions on a loose page that Jim could refer to each day:
    • What have I done today/who have I seen?
    •  What have I had to eat/drink today that I have enjoyed and why?
    • What am I thankful for today?
  • Prompting – Jim’s wife prompted him to write in the diary each day at dinner time and also to support information recall.
  • Fading prompts – Initially Jim’s wife provided daily reminders to write in the diary, but with the task repetition and habit forming the prompts decreased in specificity and frequency from “You need to write in your diary” to “Is there something you need to do?”
  • Errorless learning – Jim used the diary elastic to support navigation to the correct day in the diary and his wife supported him with this if needed, by providing positive prompts to ensure diary entries were on the correct days. They chatted about their day over dinner and his wife encouraged him to recall things he had done, using the prompt questions to help him to recall the details.
  •  Effortful processing – Thinking about, writing down and saying our loud what he was writing as he did so supported the use of cognitive abilities and the formation of neuronal networks. In addition, Jim read the diary entry out loud after he had written it, then covered the page and recalled the points.

  • Mnemonic, semantic and multimodal elaboration – When chatting about their day, Jim’s wife used word/topic association and rhyming to help prompt recall. These were chosen by Jim so that they had personal meaning and therefore would be more memorable. They included phrases such as “I ate my curry in a hurry”, “The mental lentils”, “Shrinking spinach” and, colour-word association (such as green broccoli) and hints of “it begins with” and providing the first letter of the word.
  • Expanding rehearsal – Jim practised saying out loud as a list, the things he had done that day, without looking at his diary. He repeated this after 1 minute, 2 minutes, 4 minutes, 8 minutes and 15 minutes) each evening after dinner.
  • Emotional Support – One of the written prompts asked: ‘what I have done today that I am thankful for’ to support Jim with positivity and well-being.

Jenny also took an active role in supporting both her parents in working towards this goal,  through a mix of face to face and telephone contact to support with the expanded rehearsal aspect in particular—her Mum found this harder to grasp, and struggled with at times due to her own fatigue.

Jim attained 100% of this goal over the course of seven sessions. He was able to complete the diary entry correctly and say out loud three things that he had done that day.

Emma also observed how his responses to these questions became more detailed and elaborate throughout the process, which was lovely to see. Jim was able to see this as well by looking back through the diary. At the beginning his responses to the questions tended to be one or two word answers, and then gradually developed into full sentences with more description.

Emma noted that there was a general improvement in Jim’s mood, engagement and social interaction as the sessions progressed. This was particularly evident in the diary goal, with noticeable improvement in terms of Jim’s ability to offer up and elaborate on information and engage in more meaningful and abstract discussions.

While there continues to be an improvement in Jim’s conversational ability and confidence, the video calls have become more difficult because of unrelated health issues within the wider family. This has compromised the ability of Jim’s circle of support to continue, and it illustrates the importance of the need for the statutory services to provide the continuity that would ensure that the rehabilitation model is sustained.

JP: Did anything surprise you?

Jenny: I did not realise occupational therapists have such a wide ranging role, and I was so impressed with the rehabilitation/enabling way of working. I saw how my dad was becoming less withdrawn and that my mum was grasping concepts about the importance of routine and linking things together (eg. tea and tablets, dinner and diary).

JP: Did anything feel too difficult?

Jenny: My mum was too tired in the evenings to really do the rehearsals but we found a way of doing this through other family members by phone and it gave us more contact points with my dad.

JP: What was your Dad’s main achievement because of the sessions with Emma? 

Jenny: Keeping the diary every day and spending time thinking and writing, then talking about it later. It stopped the days passing in a fog of frustrating things which weren’t working (forgetting what he had forgotten, pushing paper round a desk and not finishing anything)

Jenny’s final thoughts:
JP:  Do you think that the service that Emma provided was helpful?

Jenny: Yes very much so. I think we were lost without it and it has given us a common vocabulary to talk about what my dad needs, and given us some tools to support and encourage him and us.

JP: Is there anything else that you would like to share about your experience of GREAT CR?

The degree of involvement and understanding Emma had of my dad’s illness and my mum’s support of him meant that she was able to suggest things which have made a difference to how they are approaching things. The targets steered him away from dangerous things (chopping wood in the dark) to safer things which were still empowering (making sure the fire was laid after breakfast when he is stronger and more alert and it is day light)

I would like more people to know about GREAT CRT so that people like me who are looking for something can find it more easily. Ideally it would be available on the NHS so that there is an offer of help after diagnosis. The return on investment could be high if it keeps people able, well and happy for longer.

References
Clare L, Kudlicka A, Oyebode JR, Jones RW, Bayer A, Leroi I, et al. (2019) Goal-oriented cognitive rehabilitation for early-stage Alzheimer’s and related dementias: the GREAT RCT. Health Technol Assess 2019;23(10). https://doi.org/10.3310/hta23100
Clare, L., Collins, R. A., & Kudlicka, A. (2020). The Bangor Goal-Setting Interview – Short version – Manual (BGSI-S). University of Exeter https://medicine.exeter.ac.uk/v8media/facultysites/hls/healthandcommunitysciences/documents/The_Bangor_Goal-Setting_Interview_-_Short_Version_Manual_v116_03_2020.pdf
Clare L, Kudlicka A, Collins R, Evans S, Pool J, Henderson C,
Knapp M, Litherland R, Oyebode J, Woods R. (2023) Implementing a home-based personalised cognitive rehabilitation intervention for people with mild-to-moderate dementia: GREAT into Practice.
BMC Geriatr. Feb 13;23(1):93. doi: 10.1186/s12877-022-03705-0. PMID: 36782122; PMCID: PMC9925212.University of Exeter: GREAT Cognitive Rehabilitation – eLearning course https://sites.google.com/exeter.ac.uk/great-cr/for-practitioners/elearning-course?authuser=0