Working as an independent occupational therapist has given me the opportunity to work with patients who the NHS cannot always support, for example people who continue to have functional difficulties a few years after their stroke or brain injury. Through this experience I have seen what huge barriers weight gain, inactivity and anxiety and depression are to participation in valued roles and I have encountered ‘healthy living’ as a meaningful occupation. I wanted to write this blog to explore how occupational therapy might help people with cognitive impairments to maintain a healthy lifestyle after a brain injury. This is an area which seems largely unexplored so any comments are welcome - it would be great to share experience with others in this area.
The barriers to ‘healthy living’ for those with cognitive impairment
Consider the cognitive processes required to eat well and exercise regularly - it is a huge challenge at the best of times - scheduling time to exercise, prioritising exercise over childcare/ work/ having a social life, the discipline and self-monitoring needed to resist a Five Guys, shopping for expensive healthy foods to plan meals in advance and the list goes on.
Now that we agree that healthy living can be a seemingly impossible task, add to that: physical, cognitive, and emotional difficulties from a brain injury and you are left not only with a hugely challenging task but one that is now even more relevant and crucial. You could argue that healthy diet and exercise are even more important for someone with a brain injury as they are more at risk of secondary health problems (stroke, flu, musculoskeletal pain), unemployment, anxiety and depression. Excessive weight gain in this population would even further increase their risk of chronic health problems.
I had a quick look (not a literature review!) to see what research has been done in this area. I found nothing regarding the occupational therapy role but there are some studies about weight changes after brain injury (Crenn et al., 2014) and Sheffield Hallam has completed a longitudinal study looking at weight gain in the stroke population (Homer et al., 2014).
Crenn et al (2014) studied 107 people with traumatic brain injury over a median period of 38 months post-injury. They found that 42% of patients gained weight and 28% lost weight. Higher pre-injury BMI and impaired executive functioning were associated with weight gain.
From what I can see, there are a long list of reasons why someone with cognitive impairment from a brain injury will struggle to maintain a healthy lifestyle:
Reduced levels of activity due to loss of independence. Even activities we wouldn’t consider as ‘exercise’ like going up the stairs or walking to the toilet are no longer easily achieved. 71% of responders in the Sheffield Hallam study reported being less active following their stroke.
Loss of control over doing their own food shopping and meal planning
Cognitive difficulties with planning and prioritising make healthy meal planning challenging
Difficulty following a new recipe due to cognitive impairments
Many of my patients with reduced insight struggle to see the link between healthy eating, exercise, and positive health outcomes and weight loss
Lack of self-monitoring and self-awareness
Increased risk of depression which can be associated with lack of physical activity, isolation, weight gain and many medications have side effects. Anxiety and depression were the highest rated problems in the Sheffield Hallam study.
Difficulty with new learning or changing habits (concrete thinking)
Many people find themselves unemployed which is another cause for inactivity - 46% of people in the Sheffield Hallam study were no longer in work following their stroke.
Hormonal imbalances after injury to pituitary gland or hypothalamus - can lead to hypothyroidism (Headway)
Medication side effects often include weight gain
This problem list could go on and on, but I don’t think many people would need more convincing. I am more interesting in exploring what the occupational therapy role might be to support people to overcome these barriers. I have had a handful of patients who had goals in improving their health and losing weight but struggled due to cognitive impairment and other factors in the long list above. I have listed some of the strategies I used with them and would be interested to hear from other therapists who could add to this list.
Strategies to support ‘healthy living’ for those with cognitive impairment
Education with the client - I used the government Eatwell guide as a simplified explanation of the nutritional value of foods (see below). Involving a dietitian would have been great but we didn’t have one for any of these clients.
Education with the care team/ family is important as carers often had a lot of control around food shopping/ meal prep. I emphasise that participation in activities such as hanging out laundry, going food shopping and participating in hobbies were also valuable exercise.
Goal setting - Like any other area of intervention, setting a goal in this area is crucial. With one client we set a goal ‘to exercise regularly and eat healthily to lose weight’ (we set a goal in terms of dress size, not actual weight). We agreed that she would go to the gym 3 times a week and go on a walk or use the exercise bike on the other days. We set specific targets to cut back on sugar and white bread, in line with the Eatwell guide.
Use of a whiteboard meal planner - I set up a health/ fitness whiteboard planner which the carers helped one of my clients to use. She would plan and write down the meals for that day, reinforcing the goal of eating healthily to lose weight and also schedule what exercise she would do and when.
Motivation/ rewards - The whiteboard was also used to review daily and weekly progress and give positive reinforcement. If there is a psychologist involved they might suggest more strategies for motivation.
Education about exercise - Liaising with the physiotherapist if possible is important. A physio working with my client developed a home exercise programme that my client could complete on days where she did not want to walk outdoors or go to the gym. Allowing her more choice helped her take ownership.
Traffic light system - One of my clients had poor insight and a lack of awareness of the nutritional content of food. I used the traffic light green/orange/red system often displayed on food to support her understanding. We went through the contents of her kitchen and looked to see if the label was mostly green orange or red. I printed the code for carers and the client to refer to when meal planning, shopping, and deciding on snacks.
Adjust the environment - We moved the couch and dining table further away from the kitchen to encourage one client to walk more during the day. We also grouped certain foods together to facilitate understanding of healthy and unhealthy foods (all sugary snacks in one cupboard
Fitbit / activity tracker - One client started to wear a fitbit which helped them monitor their activity levels day to day and compare with family or carers as a motivational tool.
Cognitive strategies to support meal preparation - Using strategies such as simplifying the recipe and practicing/ repetition helped to build confidence learning new ways of cooking. I couldn’t find many resources for this for an adult brain injury population (mostly adults with learning disability) so I made up some examples for my client and her team to add to.
Exercise on prescription from GP - You can get exercise on prescription from the GP where a personal trainer can support your client with a gym programme. https://www.gponline.com/benefits-prescription-exercise/article/739863. https://www.nice.org.uk/guidance/ph54.
Having reflected on these clients and explored ‘healthy living’ as a meaningful occupation in a brain injury population, I think there are great opportunities for research here. The difficulty will be our lack of long term therapy follow up for patients who have had an acquired brain injury.
I’ve included links to some of the resources I have referred to if anyone is interested.
Please drop a comment so we can continue the conversation!
Reading list
Crenn, P., Hamchaoui, S., Bourget-Massari, A., Hanachi, M., Melchior, JC., Azouvi P. (2014) Changes in weight after traumatic brain injury in adult patients: a longitudinal study. Clinical Nutrition 33(2):348-53
Homer, C., Tod, A., Allmark, P., Bhanbhro, S., Ibbotson, R. (2014) Weight gain after a stroke : the issue and control. RCN Annual International Nursing Research Conference, Glasgow, 2-4 April 2014. http://shura.shu.ac.uk/8220/
Online forum discussing personal experiences of weight gain post-stroke: http://www.strokeboard.net/index.php?/topic/6536-weight-gain-since-stroke/