The Memory Unit OT

If you’re new to the game (or you’ve been in the game too long to remember), let’s start with a basic definition.

‘Just Right Challenge’ refers to that sweet spot where an activity is both achievable and challenging. Something that the Client can successfully do, but not so easily that there is no therapeutic benefit to performing the activity.

And it’s done by grading (aka adapting or modifying) the activity based on the Client’s current presentation, current abilities, and current goals for improvement.

In grad school, I think we often think of just right challenge in a physical sense.

And usually in relation to either a pediatric or an acute rehab setting. An obstacle course that perfectly challenges all sensory systems. A weight, a repetition level, or a distance that makes the patient sweat but not collapse. Exercises that break down just enough muscle to build back more.

And these are totally great examples of what just right challenge can look like. And we absolutely can build muscle, address balance, and improve mobility using just right challenge in individuals living with dementia.

But there is also a functional aspect to the just right challenge.

You and I find our own ‘just right challenges’ in the day to day aspects of our lives all the time. Instead of carrying the entire Costco haul into the house at once, I take trips to and from the car. Instead of cleaning the entire house in one day, I clean different rooms throughout the week. Instead of scheduling 50 things on Monday, I spread events and plans out across my calendar. I prioritize the important things, allowing myself to be flexible with things that aren’t immediately essential. I make modifications to keep my daily tasks do-able, while also keeping on top of my to-do lists and schedules.

Just Right Challenge in dementia care is a blend of the physical, the cognitive, and the functional.

It takes into account the physical needs, the cognitive abilities, and the functional goals. Just like all good Occupational Therapy intervention does.

So let’s talk about it practically.

One. Don’t make assumptions until you see what they can do. You’ve gotta figure out your patient’s full capability before you start grading tasks. Read the admission paperwork. Talk to the family members. And then treat and approach every task as if “it’s totally no big deal that I’m asking you to do this”. So think “Hey, let’s take a walk” instead of “Can you walk?”. “Let’s make this craft” instead of “Can you hold a paint brush?” Open up the floor and see what they can do.

Two. Increase the challenge by one category or element at a time. So instead of increasing both reps and weight during exercise, pick just one. Increase by one category when adding to a sorting activity. Progress from “Would you like some ice cream?” to “Would you like chocolate or vanilla?” then to “Which flavor would you like?”.

Three. Read the signs. Individuals living with dementia can’t always tell us exactly how they’re feeling. So be on the lookout for other ways they might communicate that the challenge is just too much. It could be a sudden change in mood, an attempt to change the subject, falling asleep or becoming distant, or even getting outright leaving the activity.

As with all therapeutic grading, it comes with trial and error. There’s no perfect formula to know exactly what the just-right challenge is. And the more you work in this field, the more you’ll get a good sense of what activities grade well, what strategies allow for smooth transition from one grade to the next, and how to quickly and efficiently read the signs to keep the session on track.