Can Your Older Adult Clients Walk and Chew Gum?

Our older adult clients have a finite amount of attention to devote to the motor and cognitive demands of everyday life. Dual-task training is a powerful treatment tool in geriatric physical therapy and can improve dual-task capabilities, but we must strategically choose our dual-task training paradigms.

A Full Bucket

The intricate relationship between cognition and gait is indisputable. Imagine a finite amount of attention that an individual can devote to motor and cognitive demands in any given situation: A bucket full of attention. When the cognitive and motor attentional demands of the situation do not exceed what’s in the bucket, there is an attention surplus, often leading to a demonstrated success with both the cognitive and motor tasks.

When demands exceed the attention capabilities in the bucket, there is an attention deficit, and something’s got to give. Clinically, this is seen as degradation of performance of either the motor task, the cognitive task, or both.

Keep it Simple

As we age, the facility with which we dual- and multi-task diminishes, but fortunately, dual-tasking and multi-tasking are responsive to training. While there has been some recent excitement and interest in using video games and virtual reality equipment as clinical strategies to introduce cognitive demands to mobility training, all clinics don’t have the equipment and/or expertise to integrate this training. Luckily, there are many other simple ways to superimpose cognitive demands on clients while practicing gait or mobility training.

The Right Level of Challenge

There is evidence supporting the effectiveness of dual task training in older adults; however, the mode of training depends upon clinical goals.^1,2 It may be appropriate to begin with rote, easy cognitive tasks (e.g., counting, reciting alternate letters or numbers), or by superimposing motor tasks vs. cognitive tasks in training (e.g., carrying an object while walking or demanding a motor response to instruction during a task).

The dual task “cost” is greater with executive function tasks, and training at this higher level will better prepare our older adult clients for real-world cognitive demands.³ While training may not increase the size of an older adult’s attention bucket, it may help them decrease the attentional cost of dual-tasking, allowing them to more effectively utilize the contents of their bucket.

Cognitive Tasks to Superimpose on Gait or Mobility Training

Here is a brief list of tasks that can be superimposed on gait or mobility training modes:

• Naming words starting with a particular letter or in a specific category (e.g., fruits, farm animals, pizza toppings)
• Spelling words backwards
• Memory recall of a list of words presented prior to the task
• Counting backwards by 3 or 7 from an arbitrary start number
• Mathematical calculations
• Visual searches for landmarks in the environment
• Contrasting visual and auditory cues with instruction to selectively attend to one over the other (e.g., arrow points right, but verbal instruction says “left”)
• Visual-spatial clock task – State a time, and client has to determine if the hands of the clock would be on the same side (left or right) or opposite sides of the clock

Preparing for Real-world Challenges

Dual- and multi-task training can be fun, yet challenging and engaging for our clients. The most relevant training requires us to know each client’s specific mobility goals and the environment(s) in which they aspire to function. Armed with this information, we can create therapeutic dual- and multi-task challenges that mirror the real-world challenges. We want our clients to maximize their dual-task functionality, but to also respect the limits of their buckets.