Dementia final
Retrieval Cues
"Encoding Specificity Principle" Eg: having witnesses return to the scene of the crime to trigger recall therefore to facilitate learning, use retrieval cues that reflect support given at encoding. Note: This means you have to keep track of the cues that were used previously. Also, questions should not be worded differently than when information was originally taught.
Having Something to Nurture
A highly successful approach to designing nursing homes is to provide patients with something to nurture: Eden Alternative (Thomas, 1996) E.g: pets and plants Nursing homes should be human habitats where residents live, feel useful and needed, and even thrive As opposed to a place where they go wait to die. Residents should be given an opportunity to give as well as receive care.
Spaced Retrieval Training (SRT)
A repetition based shaping procedure in which the client recalls information over increasingly longer intervals of time Eg: a name, a procedure, a location, etc A simple procedure requiring little cognitive effort from the client SRT can be nested in other activities such as conversation, physical therapy, or doing a craft project And used by both personal and professional caregivers
Don't Repeatedly Correct, cont.
A strategy for indirectly correcting a patient with an erroneous idea is to provide the correct information in the patient's memory wallet of scrapbook. Frequent use of these aids may help the patient to stay informed One moderately demented patient frequently told caregivers that her son was coming home from school and that she need to make supper The caregiver put her son's picture in his Navy uniform on her nightstand and every day reviewed the fact of his being at sea In a few days confusion diminished and she told people that her son was in the Navy.
Use a Peaceful Organized Environment to Support Basic ADLs
Additional recommendations on p. 237 Physical characteristics of an environment influence how people feel and respond. Each patient's environment should be analyzed regarding what it evokes in terms of mood, language and action Particularly important for patients exhibiting negative behaviors or who are highly agitated See recommendations listed on p. 237
Reducing Verbal Perseveration and Disruptions
Admonishing repetitious patients to stop repeating is ineffective because they can't remember the admonitions or that they already said something. Moderate-Severely demented patients produce disruptive vocalizations such as screaming and repeatedly calling out This may be a sign of physical discomfort, emotional distress or too much/too little stimulation Recommendations are listed on p. 239
Tarraga et al, 1996
After 12 weeks, the patients treated with both IMIS and IPP had improved outcome scores on the ADAS-Cog and MMSE, which was maintained through 24 weeks of follow-up. All IMIS patients had improved scores in all of the IMIS individual tasks, attaining higher levels of difficulty in all cases The patients treated with IPP alone had better outcome than those treated with ChEIs alone, but the effects were attenuated after 24 weeks. IMIS and IPP groups both improved more than the CHEI only group on the MMSE and the Alzheimers Disease Assessment Scale - Cognitive (ADAS - Cog).
Medications for early to moderate stages
All of the prescription medications currently approved to treat Alzheimer's symptoms in early to moderate stages are from a class of drugs called cholinesterase inhibitors. Cholinesterase inhibitors are prescribed to treat symptoms related to memory, thinking, language, judgment and other thought processes. Cholinesterase inhibitors: Prevent the breakdown of acetylcholine (a-SEA-til-KOH-lean), a chemical messenger important for learning and memory. This supports communication among nerve cells by keeping acetylcholine levels high. Delay worsening of symptoms for 6 to 12 months, on average, for about half the people who take them. Are generally well tolerated. If side effects occur, they commonly include nausea, vomiting, loss of appetite and increased frequency of bowel movements. Three cholinesterase inhibitors are commonly prescribed: Donepezil (aka Aricept) is approved to treat all stages of Alzheimer's. Rivastigmine (aka Exelon) is approved to treat mild to moderate Alzheimer's. Galantamine (aka Razadyne) is approved to treat mild to moderate Alzheimer's.
Self-generation, cont.
Another study had patients provide general properties of 10 nouns, compared to making yes/no judgments of whether the object was a member of a category provided by the clinician AD patients remembered better using their self-generated cues, as opposed to the clinician's category cues (Lapinska et al, 1994) Opportunities to use retained knowledge can be provided through reminiscence sessions, cooking and community activities.
Use: Questions and Requests
Ask multiple choice or yes/no questions Avoid open ended questions which place the patients in a free recall situation Patients also have trouble generating ideas, so it is helpful to give them choices See Table 14-1 Also use direct rather than indirect requests Indirect: Could you pass the sugar? Direct: Please pass the sugar. Or, "Why can't I ever find the remote?" for "Where's the remote?" Be direct but polite.
Use Neuroplasticity Principles to Support Learning and Maintenance of Knowledge & Skills
Attention - secure client's attention, stimulus should be relevant and should be associated with a reward Reward and Emotion are related and stimuli should be emotionally rewarding to the client Stimulation - Stimulate the use of retained knowledge and skills And learn compensations for those lost Forms of stimulation for dementia patients include: Priming, Active Engagement and Elaborative Encoding
Example Uses of SRT
Both fact knowledge and procedures can be taught with SRT Examples of useful facts are: Previously known but forgotten personal information Name-face associations of caregivers and family members Location of important objects 911 as an emergency number Examples of useful procedures: Making a phone call for help Making a safe transfer (to or from the wheelchair) Finding locations (bathrm, bedrm, nurses station, dining rm) Increasing volume of voice Operating a faucet Inserting a hearing aid
Memory Books & Wallets
Bourgeois (1992) has shown that some dementia patients are more likely to produce meaningful utterances when these aids are the stimulus to conversation. The Memory Wallet is a compilation of pictures and sentences about the patient's life. The Memory Book is a larger more elaborated version of the memory wallet. The patient does not have to actively recall the pictured events, merely recognize them. Memory books include biographic information and facts about people important to the patient that has been simply stated and paired with pictures and other memorabilia.
Restorative Therapy
Clients are brought to the functional level they are capable of but have not been achieving
Self-generation of a Response
Clients have better memory for words that they generate in response to cues, rather than simply listening or looking One study had subject with AD read S-V-O sentences vs provide an object for S-V-O sentences ("The gentleman opened the ____.") Self-generated Objects were better than those already present when reading. Mitchell, Hunt & Schmitt, 1986
Color Discrimination
Color discrimination is impaired in AD. Difficulty with blue vs green and blue vs violet, while red is well preserved as is brightness High color contrast in the environment is helpful, e.g. table and counter tops should contrast strongly with the floor, dishes should contrast with the table top, etc. Best contrast is dark color against a light background or visa versa Poor contrasts are dark green/bright red, yellow/white, and lavender/pink
"Life Story Work"
Computer aided development of the life stories of dementia patients is being widely studied as a tool to benefit patients and caregivers Development of life stories enables the staff to see the personhood of the individual with dementia And helps the patient maintain memory of life events Life stories stimulate conversation and provide comfort to agitated patients This seems like a direct extension of the memory book concept for the 21st century!
Scottish Prompting System: Pilot Study
Conversational support and prompting system Uses touch screen technology to access a multimedia reminiscence presentation that prompts conversation Rationale: Dementia patients have difficulty conversing because of deficits to freely recall information and events The conversation support system compensates for the difficulty by providing information that patients have difficulty recalling but retain in long term memory Thereby stimulating reminiscence
Good Themes for Reminiscence Sessions
Culturally appropriate holidays Personal milestone events (getting married, graduation) Notable world events Weather events National traditions Geography (Interesting Places)
Spaced Retrieval Training, cont.
Davis, Massman & Doody (2001) conducted a randomized, placebo control study with 37 AD patients to study SRT Home administered attention exercises (cognitive stimulation) was the placebo condition Patients in the SRT group improved in recall of personal information during the 5 week intervention The placebo group did not improve
Processing Time
Declines with normal aging from 65 to 91 yrs, affecting performance on neuropsychological testing Dementia patients are even slower, as a function of both age and of pathology Allowing additional processing time is another way to reduce task complexity
Do Not Repeatedly Correct the Patient
Dementia patients often make erroneous statements Caregivers embarrass them by correcting misinformation, particularly when other people are present Once the patient has been put on the defensive, agitation and hostility may result, And he or she loses the desire to talk
Minimize Error Responses
Dementia patients with episodic memory problems typically forget their error responses And do not self-correct as normal adults do in trial and error learning When an error response is repeatedly produced it is strengthened, making it more likely to occur in the future Errorless Learning - procedures can be used to teach a variety of tasks to patients with memory problems It provides sufficient cueing or scaffolding to minimize errors with gradual fading of cues as the target is learned Guessing is discouraged Trial and error learning requires self-insight and monitoring, whereas errorless learning is less effortful
SenseCam
Designed to make a visual record of the events experienced by the individual wearing it A small digital camera can be worn around the neck and can be programmed to automatically take photographs at certain times All sensors are built in and monitored by a microprocessor Changes in sensor readings can trigger the camera to take a picture (e.g., body heat of someone near the camera) It is being tested for a variety of uses
Medication for moderate to severe stages of AD
Donepezil (Aricept) is the only cholinesterase inhibitor approved to treat all stages of Alzheimer's disease, including moderate to severe. A second type of medication, memantine (aka Namenda) is approved by the FDA for treatment of moderate to severe Alzheimer's. Memantine is prescribed to improve memory, attention, reason, language and the ability to perform simple tasks. It can be used alone or with other Alzheimer's disease treatments. There is some evidence that individuals with moderate to severe Alzheimer's who are taking a cholinesterase inhibitor might benefit by also taking memantine. Memantine: Regulates the activity of glutamate, a different messenger chemical involved in learning and memory. Delays worsening of symptoms for some people temporarily. Many experts consider its benefits similar to those of cholinesterase inhibitors. Can cause side effects, including headache, constipation, confusion and dizziness.
Elaborate Encoding
Elaborate encoding, or greater depth of processing of information builds stronger "engrams" for the information Memory improves when strategies such as visual imagery or organization of information to be learned are provided during encoding Such strategies promote greater depth of processing Thinking of or stating attributes of an object instead of only recall it without elaboration (i.e., elaborate encoding) The greater the depth, the greater the learning This applies to persons with dementia as well as to healthy elders and younger people
Errorless Learning, cont
Elimination of errors is achieved by: (1) breaking down the targeted task into small, discrete steps or units; (2) providing sufficient models before the client is asked to perform the target task; (3) encouraging the client to avoid guessing; (4) immediately correcting errors; (5) carefully fading prompts" (Sohlberg, Ehlhardt, & Kennedy, 2005, p. 272). Errorless learning has been found to be most beneficial for those individuals with relatively unimpaired procedural memory and severely impaired declarative memory. High amounts of correct practice, distributed practice, forward-and-backward chaining, and effortful processing have been found to facilitate errorless learning (Sohlberg et al., 2005). Commonly used treatment methods, such as spaced retrieval (Melton, Bourgeois, 2005; Haslam, Hodder, & Yates, 2011) and the method of vanishing cues (Sohlberg et al., 2005), are based on principles of errorless learning.
Music and Dementia Treatment
Emotional memories are easier to recall than unemotional, and music stirs emotion In a study of recounting autobiographic detail, music chosen by the subject vs Vivaldi's "Four Seasons" vs Silence Normal Elderly and Dementia Patients did better after hearing the self-chosen music Musical semantic memories (melodies and lyrics) may be an "island of cognitive preservation" It increases arousal and interest, and yields greater animation, greater action, and increased verbal output
Content: Talk about the here and now
Episodic memory impairments make it difficult for dementia patients to talk about things that they cannot see and feel It's best to talk about objects that are present Doing an activity will provide something to talk about Activities like arranging flowers, building an object, sewing, painting can provide topics for conversation about the here and now
Form: Pleasant and accepting vocal tone
Everyone becomes uncomfortable when someone speaks in an unfriendly tone Even patients who can no longer comprehend word meanings respond to prosodic and emotional characteristics of speech Clinicians and caregivers who use a friendly vocal tone evoke a positive reaction from the patient Condescending vocal tone also creates emotional distress and interferes with comprehension Note: "elderspeak"* is offensive to older patients, with or without dementia *talking to the patient as if s/he were a child
Use: Nonliteral Language
Exaggerating, teasing and sarcasm are not helpful for patients with dementia E.g., "You look so good today that all the girls will be asking you for a date!" Also avoid idioms, similes and metaphors, or figures of speech "he hit the ceiling" "Life is like a bowl of cherries" or "life is a carnival" "It's raining cats and dogs" Assistive listening devices (e.g., voice amplifiers) may also be helpful
Omnibus Reconciliation Act of 1987
Federal legislation that governs accreditation of long term care facilities Requires that residents be comprehensively evaluated And that care plans be developed that will enable them to function at their highest level of ability SLPs routinely receive reimbursement for assessing the individuals ability to improve If improvement is expected and SLP skills are needed, reviewers will approve "restorative therapy" If, after a restorative trial, the restorative potential is judged to be insufficient, the clinician can develop a "functional maintenance plan" (FCP).
Form: Multimodal Input, cont.
For example, to teach a name it is better to: Explain the name Show the patient its written form Have the patient read the name, then write it Associate it with a face or picture that can be described For AD patients, who can read words well into the course of AD, it's helpful to use Visual as well as auditory stimulation And to provide the object being discussed
When patients forget the topic, summarize what has been said
Frequently, dementia patients forget what they intended to say, causing an interaction failure. A thoughtful listener can summarize what has been said to enable the patient to continue. This also helps the patient to save face. See example interaction on pg. 233
Reminiscence, cont
Good reminiscence sessions require planning The clinician should selecting a theme, and obtain related tangibles, Also develop a list of questions that probe for the obvious and less obvious recollections that participants are likely to have Plan how to include all group participants, eg. Have some members describe a tangible item, then ask others what they think about the tangible Group members can share responsibility for reading news paper articles and article headlines Reminiscence can be a stimulus for physical activity, such as dancing, food preparation or excercise
Additional Elaborative Techniques
Have learners listen to a text, identify key propositions, and later use them in a story they create Question Asking and Reading (QAR) to increase memory for content of stories Reading of the text was distributed among group members And scripted to include text based questions that group members had to answer QAR increased the learning of text and frequency of verbal interaction among group members A 3 step strategy is also described for making face-name associations (see p. 217 in text)
Dolls & Stuffed Animals
Hopper et al (1998) used dolls and stuffed animals in single subjects designs to investigate efficacy for communication in 4 female patients with moderate AD. Study participants produced more relevant information units when these supports were used than when questions alone were used. AD patients clearly enjoyed the toys as evidenced by hugging and talking to them.
Letter Writing
If the patient wishes to write a letter, supply the materials, a list of news items, and a picture of the letter's intended recipient This type of support will make it easier for the patient to be successful A few written news items eliminates the need for the need for the patient to remember and may stimulate related memories Being able to see the person for whom the letter is intended will sharpen the patients focus
Cognition-enhancing medication
Improves mental function, lowers blood pressure, and may balance mood: Donepezil (Aricept) Galantamine (Razadyne) Memantine (Namenda) Rivastigmine (Exelon)
Spaced Retrieval Training, cont.
In SRT the clinician controls: The type of target response Duration of the intervals between retention probes The number of learning trials The first intervals between recall probes are relatively short and are gradually extended When an incorrect response is given, the clinician returns to the last length of interval that produced a correct response Activities between retention probes can be related to the desired response or unrelated. SRT has been used successfully with dementia to teach various types of information, including: Face-name associations Object location Object names Various verbal and motor responses SRT was used effectively to teach five dementia patients 3 pieces of information (Brush & Camp, 1988) therapist's name, a fact important to the person, a compensatory technique for communication Maintenance at 1 month follow up varied across patients
Self-generation and Priming
In a word stem completion task , in which the client saw the word first then later had to complete the word E.g., Patient is shown the word "lettuce" then later has to complete the fragment "Let____" AD patients performed equal to healthy elders when they had to make a semantic judgment about the prime, but poorer than healthy elders when they just read or heard the prime. Millet, et al. 2010
AD Specific Visual Impairment
In addition to normal aging deficits, AD causes deficits in color discrimination and contrast sensitivity Sensory loss can negatively affect the ability to communicate, perform tests and carry out daily activities Vision is needed to read lips, interpret facial expressions, interpret contexts, follow directions, and read Consequently, clients may appear to be more demented than they really are, in terms of both performance on tests and in carrying out activities of daily living. The need for visual accommodations is under appreciated by many professional and personal caregivers. This increases dependency and reduces quality of life
Assistive Technology for Cognition (ATC)
Increasingly being used to support functioning of the cognitively and communicatively impaired (aka "cognitive prostheses") ATC interventions are extrinsic environmental supports for Orientation, prospective memory, Communication, executive functioning And activities of daily living They can provide reminders, cue and monitor performance, alert caregivers to problems, expose patients to virtual environments, stimulate communication and help compensate for sensory loss
Form: Limit the number of conversational partners
It is overwhelming for patients to keep track of the topic and who said what to whom when several people are conversing Patients can become agitated at large family gatherings due to limitations on memory and attention Dementia patients do best communicating one on one
Priming: Indirect (Associative)
Item presented in the training as associated with the item to be produced Associative priming is conceptual or semantic Commonly used tasks are word associations, category productions, or general knowledge Clinically SLPs use verbal associative primes to cue patient responses They also use more complex associative primes such as routines, memory books or wallets, music and contexts
Improving Language Comprehension
Language comprehension is a complex, multistage process Listeners must analyze the form, content and context in which an utterance is spoken To derive the proposition(s) being expressed. Techniques for facilitating comprehension can be subcategorized as to whether they involve Form, Content Or use of language (context)
Form: Multimodal Input
Learning and comprehension are better when information is experienced in more than one modality e.g., auditory + visual > auditory only Rapid forgetting characterizes various dementias Presenting information in one modality and then in a second modality capitalizes on the strength of repetition for strengthening encoding for AD (I note that this seems to contradict what it said in the previous chapter.)
Active Engagement
Learning is faster and better when the individual is actively engaged in the learning process Active engagement is fullest when learning by doing Action oriented learning involves the procedural memory system If individuals are provided the opportunity to practice new procedures they become habitual and increase independence. By providing opportunities for the execution of previously learned procedures, this knowledge can be sustained.
indirect intervention overview
Linguistic modifications to facilitate communication Computer supports Memory aids that improve quality of life Environmental manipulations SLPs do not carry out indirect interventions, but recommend them in care plans We teach them to caregivers and oversee their implementation Medicare will pay for these services
APPs
Many APPs for game playing and stimulation are being used by patients with mild-to-moderate dementia* For example, patients are playing a simplified version of scrabble on ipads with friends Touch screens and other intuitive operations are within the capacity of many dementia patients *Note that no evidence is provided for the use of APPs
Common changes in behavior in AD
Many people find the changes in behavior caused by Alzheimer's to be the most challenging and distressing effect of the disease. The chief cause of behavioral symptoms is the progressive deterioration of brain cells. However, medication, environmental influences and some medical conditions also can cause symptoms or make them worse. In early stages, people may experience behavior and personality changes such as: Irritability Anxiety Depression In later stages, other symptoms may occur including: Anger Agitation Aggression General emotional distress Physical or verbal outbursts Restlessness, pacing, shredding paper or tissues Hallucinations (seeing, hearing or feeling things that are not really there) Delusions (firmly held belief in things that are not true) Sleep Disturbances
Control of Task Complexity
Match task demands to the ability of the client Consider the number and type of mental operations required and the level of complexity of the stimuli For example, recognition tasks are less difficult than recall tasks Other difficult tasks are superordinate and coordinate naming, while oral word reading, reading comprehension and auditory comprehension using multiple choice format are easier. See 13-1 and discussion on p. 209
In Summary: Direct Therapies
Maximize vision and hearing Use errorless learning and cue fading Systematically control task complexity Use cued recall or recognition rather than free recall and work within client's memory span Allow more time to respond Avoid multitasking and multimodal stimuli/responses Make therapy personally relevant Secure attention and use emotion to capture it Use active engagement Use repetition of information to be learned (SRT) Use priming and elaborate encoding Use reminiscence including client-selected music
Reading Aloud
Mechanics of reading remain intact for may patients until late in the disease course Thus, this is an language production activity they can do One caregiver had her husband read popular novels aloud while she worked in the kitchen preparing food He felt useful and she enjoyed the stories Elders with dementia can read storybooks to children, their own grandchildren or at daycare centers.
Spared Systems May Compensate for Deficits
Memory deficits change with disease progression and worsening of dementia Need for periodic re-evaluation In early stage AD, the primary problem is impaired episodic memory, and demands on it need to be reduced Semantic and lexical memory are relatively functional in early to middle stage AD (but will deteriorate later) Though working memory is compromised, environmental supports help clients maintain orientation and focus attention Nondeclarative memory is best preserved and can help patients learn new behaviors Particularly when declarative memory declines Conditioning, procedural learning, priming, etc
Span Capacity of Working Memory
Memory span capacity diminishes slightly with age, but markedly with dementia Reduced span capacity can affect one's ability to comprehend task instructions. Knowing a patient's span capacity for verbal and visual information is important for designing tasks that will not be so over whelming that they discourage participation When dementia patients are given more information than they can process they tend to withdraw Verbal (digit) & visual (block) span capacity can be tested using subtests from the Wechsler Memory Scale, 3rd Ed.
Tarraga et al (1996)
Mild AD patients w/ MMSE score between 18-24 and GDS score of 3 or 4 (N = 46) in 3 groupings*: Experimental group received 24 weeks of "interactive multimedia internet-based system" cognitive stimulation (IMIS) (n= 15) in conjunction with integrated psychostimulation (nursing home activities program) (IPP) as well as CHE inhibitory meds (CHEIs) Another group had psyochostim plus CHEIs (n = 16) Another group had CHEIs only (n = 12)
Memory Books & Wallets, cont.
Mild dementia patients with MMSE scores of 19-24 received excellent benefits from these aids. Mild patients are aware that they have wallets and books and refer to them on their own. Moderate patients (MMSE scores 12-18) require caregiver prompting to use the aids. Severely demented individuals (MMSE scores < 12) may not benefit from the aids.
Indirect Interventions
Modification of the physical and/or linguistic environments to support cognition and communication
Music
Music is a potent tool for engaging patients and stimulating reminiscence It has been shown to reduce loneliness and depression and stimulate participation Playing quiet baroque music significantly reduced noise making behaviors in some dementia patients Music preferred by patients premorbidly produced a beneficial effect on behavior Clinicans should obtain information about the music preferences of the patient and provide a means of turning off unwanted music
Avoid Having Clients Multitask
Neural activation associated with a given task decreases in healthy adults if a second task is done at the same time Dementia patients are better at focusing attention on a single aspect of a stimulus than when dividing attention between two aspects of the same stimulus Multitasking can cause attention gaps, stress, trouble concentrating, and problems with recent memory Avoid competing distractions and don't work on divided attention or shifting attention (unlike TBI)
Intensity and Duration of Treatment
No direct evidence base on intensity and duration of treatment, however: Behavioral responses of the client and performance on outcome measures provide evidence as to the adequacy of intensity and therapy duration When a client loses interest in a session or shows signs of fatigue, intensity should be lowered or the session ended Duration of restorative therapy is largely depended on whether the client makes demonstrable progress Common sense suggests that a single weekly session is unlikely to make significant progress Daily sessions that provide distributed practice* are more likely to produce measurable results *a learning strategy, where practice is broken up into a number of short sessions (as opposed to massed practice)
Recognition is Easier than Recall
Patients with AD do better with cued recall and best with recognition, in comparison to free recall tasks. See Table 13 - 2 on p. 210 A simple technique to preserve the dignity of patients with severe episodic memory problems is to avoid open ended questions like "what have you been doing" or "what did you have for dinner" Instead use "yes/no" questions or simple choice questions (e.g., do you want chicken or fish?"
Prospective Memory Aids
Pocket sized devices that can recall and play back verbal messages Includes software that stores a schedule or other information Can signal users to do scheduled things via auditory and/or visual cues Mild-to-moderate AD patients were shown to perform better with the device than without it on 7 memory tasks. Two subjects had perfect scores (Zanetti et al, 2000).
Hearing and Aging
Presbycusis: Age related hearing loss is prevalent among the elderly and > in AD Hearing loss can make clients seem more demented than they actually are. Without correction, hearing loss can contribute to more rapid cognitive decline When individuals with dementia received amplification, their cognitive and behavioral functioning improved If full scale audiological testing is not available SLPs can test word discrimination by repetition or sameness judgments
PQRST Method for Elaborate Encoding
Preview, Question, Read, State, Test (PQRST) First the information is previewed Next the learner is asked to answer questions about it Then the learner reads the information Then the learner summarizes the information Lastly, the learner is tested on the information
Stimulation: Priming
Priming is advantaging a response by prior exposure to the target or a related item. It is a type of cuing. Increases the frequency, speed or accuracy of a response to a particular stimulus Eg: You will respond more quickly or accurately to the word "desert" if you have recently seen the same word, or if you have seen an associated word like "hot" or "dry" It occurs without your awareness due to spreading activation of energy within semantic and lexical memory (e.g., "bird" will prime for "eagle")
Avoid Placing Patients in a Free Recall Situation
Provide names and relevant information when people come to visit or provide services For example, a sensitive caregiver once introduced visitors as follows: "You remember Cheryl and Kathryn, dear, they are here to test your memory." The patient responded "Oh, yes, nice to see you again." Given impaired free recall, this technique preserved the clients dignity, especially in the presence of other people.
Improving Production of Language
Provide something tangible and/or Visible to stimulate conversation Gives client and clinician a common point of reference and also enhances spreading activation This will help the client with dementia call to mind other information that can be shared in conversation Memory books and wallets that contain information about the patient can stimulated language production
Lighting in long Term Care Facilities
Raise the level of illumination Provide consistent and even light levels Eliminate Glare Provide access to natural daylight Provide gradual changes in light levels in transitional spaces Provide focused task lighting Improve color rendition from light sources so that environmental colors are not distorted Normal elders need 2 to 3 X more light than a 20 yr old
Task Complexity, Summary
Recognition is easier than recall Comparing features of items is harder than item recognition Expressing relationships is harder than confirming relationships The more cognitive manipulations needed to do the task, the harder the task Complexity of stimuli interacts with task complexity Visibility of instructions enhances performance
Provide Food to Increase Sociability and Talking
Refreshments create a social context and serve as a cultural trigger for conversation Many long-term care facilities have programs in which residents gather daily to make breakfast, or afternoon tea time, and talk about world events Many dementia patients enjoy preparing food If done with supervision, can be a useful and pleasurable stimulus for socialization and conversation
Dementia Treatment Guidelines
Regardless of the cause of dementia, these guidelines are helpful in designing a care plan for maximizing function: Strengthen the knowledge and processes that have the potential to improve Reduce demands on impaired cognitive systems Increase reliance on spared cognitive systems Provide stimuli that evoke positive fact memory, action and emotion
Reminiscence
Reminiscence group therapy stimulates recall When presented with pictures, newspaper articles, video clips, clothes and props associated with a theme, Personal experiences related to the theme will come to mind This is true both for healthy individuals and those with dementia A variety of materials should be used to trigger all the senses Synergy can develop in group reminiscence sessions in which members aid each other in the recall of past events When one member recalls a memory, it stimulates memories in other group members
Priming: Repetition
Repetition is "direct priming" When the priming cue is identical to or composed of fragments of the item to be produced (e.g., Prime = Jane for response "Jane" or "Ja_ _" for "Jane" from our errorless learning example) Direct Priming is perceptual and modality specific, and independent of the meaning of the item. Common tasks include completing a word, making a decision about a word, or identifying previously seen words.
Robots, cont.
Robotic animals are being used to provide stimulation to dementia patients of all levels of severity. The best known is Paro, a baby harp seal that responds to touch and sound and is capable of learning the patterns of response of individuals who interact with it Wada et al (2005) reported that 20 mins with Paro increased cortical neuronal activity significantly Several review articles on use of robotic animals are available (see refs cited on p. 235). There are ethical questions regarding carebots
Robots (aka "Carebots")
Robots have been developed to assist elders They can be programmed with information about the elder's daily activities And have the capacity to provide needed reminders Their sensing systems can detect problems and alert caregivers Sensors make it possible to locate misplaced objects that are radio frequency identification tagged They can be programmed to call 911 if no movement from the patient is detected A robot has been developed that is basically Skype on wheels Its mobility and ease of use enables dementia patients to have Skype calls with loved ones and is reported to enhance mood and quality of life.
Supporting Feeding
SLPs frequently help with challenges of feeding dementia patients Moderate and severely demented patients often require eating assistance Environmental manipulations can improve functional feeding in many patients Suggestions are listed on p. 238
Hearing Facilitation
Screen clients for hearing and word discrimination and if needed, refer to audiologist Have clients who need hearing aids wear them Eliminate noise Ensure that clients can see the clinician's face Clinicians also can amplify their voice
Managing Visual Impairments to Facilitate Learning
Sunlight deprivation negatively impacts the health and quality of life of many elders Sunlight helps regulate circadian rhythms and many biologic processes It also can contribute to agitation, depression and to sleep disorders that can diminish cognitive functioning It has been demonstrated that exposure to bright lights can reduce agitation and improve sleep/wake cycles even in late stage dementia patients.
A House as a Cognitive Orthotic
The concept of an instrumented environment or house has been described (Mynatt. Et al. 2000). It will have information about the inhabitants activities and lifestyle And contain sensors that detect task disruptions Auditory and visual cueing systems throughout the house will assist inhabitants in the completion of multistep activities (washing clothes, making breakfast, emptying the trash) Sensors will also detect the need for emergency assistance
Creating a Safe Environment
The goal of environmental manipulation is the creation of a safe, peaceful and organized environment that evokes positive mood and behavior See list of recommendations on p. 236 A safety issue for dementia patients is driving Median duration of driving after disease onset was aproximately 2.5 yrs 22% of AD patients who were driving, were in accident in previous 6 mos MMSE scores < 18 who show visual impairment are unlikely to be safe drivers MMSE scores > than 18 w/ no visual impairment should be given an in car driving evaluation to ensure that they can drive safely on familiar routes (Gilley et al, 1991)
Content: Propositions
The greater the number of propositions per sentence, the greater the cognitive resources needed to understand it and act on it Reductions in span and executive functions limit AD patients' ability to comprehend even with 2 propositions See examples on pp 228-229 Use of short simple sentences Avoid embedding, passives, cojoining (conjunctions), and left-branching syntax
Direct Interventions
Those provided by individual or group therapy that enable dementing clients to maintain residual knowledge and skills.
Errorless Learning Approach
To reduce likelihood of error responses, SLPs can manipulate stimulus characteristics and response contingencies Vanishing Cues are employed to reduce errors in amnestic individuals (as in AD) Learners are given strong cues at first Gradually, cue strength is reduced until the client responds correctly in the absence of cues Eg: to teach the name of the nurse, Jane, first the written name is provided as a full cue in response to the question: "What is the name of your night nurse?" On subsequent trials the patient would read the card in a reduced form (Jane, Jan_ , Ja_ _ ) etc This method has been used successfully with demented and non-demented amnestic patients.
Content: Vocabulary and Reference
Use high frequency words: E.g., The philatelist was a centenarian. vs The stamp collector was a hundred years old. Replace Pronouns with Proper Nouns Dementia patients have difficulty keeping tract of pronoun antecedents Repeating the proper noun, rather than using a pronoun, helps facilitate comprehension E.g., "John and Mary went to see Bill before Bill left for college. John and Mary wanted to wish Bill well." Also, revise and restate that which is not understood (in a non-condescending way) to facilitate comprehension
Form of Language: Rate
Use slower than normal rate of speech Dementia causes slowness of processing The greater the number of words spoken per minute, the greater the number of concepts to process per minute. Measure your rate of speech, and if one is a fast talker, slow rate to slightly below average Average = 160 - 170 words/min
Cognitive Orthosis for Assisting Activities in the Home (COACH; Mihailidis et al, 2001)
Uses AI to help demented persons with ADLs And a videocam connected to a computer to monitor behavior E.g.: it can monitor hand washing and provide verbal prompts Hand washing behavior was tested for 60 days with 10 individuals with moderate to severe dementia Number of hand washing steps completed w/o care giver assistance increased by 25%
Something to Nurture, cont.
Using this model, Thomas reported that residents experienced Fewer UTIs Decrease in upper respiratory infections Decreased medication use Fewer deaths Also decreased staff turnover Fewer behavioral incidents Decreased restraint use Lower levels of boredom and helplessness in comparison with non-Eden Alternative facilities
Perceptibility of Stimuli
Vision deteriorates with advancing age Presbyopia - loss of focusing power, impaired depth perception, and need for more light, also slower adjustment to levels of illumination Reduced pattern perception and increased need for contrast to aid perception Other visual problems with aging Cataracts, glaucoma, macular degeneration, diabetic retinopathy Blurred vision, blind spot and increased sensitivity to light, altered color vision Eye stops growing in adolescence, but lens continues to grow during adulthood becomes denser and less elastic
Planning Direct Therapy
When planning therapy, use emotional stimuli that evoke positive emotion and action in the patient Neither individuals with dementia nor caregivers benefit from creation of a negative emotion Negative moods can persist long after the provoking stimulus is forgotten, increasing caregiver stress, staff time, and decreasing the patient's quality of life. We should also consider the principles of neuroplasticity (see Chap. 1, Table 1-1, p.4) Also consider: Perceptibility of stimuli, span capacity of working memory, and task complexity
Repetition
When we repeatedly access information and bring it to conscious awareness, the engram for the information is strengthened, making it more accessible for future recall Many researchers have demonstrated that repetition facilitates learning in dementia patients We use forms of repetition in, for example, Errorless Learning and Spaced Retrieval Training. If the information to be learned is new, learning will be slower and it will be forgotten more quickly with dementia If so, the focus should be on maintaining preserved knowledge through repeated opportunities to use it Eg: names of grandchildren, how to make a 911 call and other functional activities
Functional Maintenance Plan
a plan of care designed to maintain clients at a particular level of functioning SLPs' time involved in plan development and time needed to instruct supportive personnel, plus periodic oversight are reimbursable services If FMP is created during the period of diagnostic or restorative therapy.
