fsm office for corporate relations - ksha

9/22/2016

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Becky Khayum, MS, CCC-SLP

MemoryCare Corporation Co-Authors: Darby Morhardt, PhD, LCSW Emily Rogalski, PhD Northwestern University - Cognitive Neurology and Alzheimer’s Disease Center

Toss the Workbooks: Evidence-Based Approaches for

Person-Centered Dementia Interventions

Disclosures: B. Khayum, M.S., CCC-SLP

Relevant Financial Relationships

Owner of a for-profit company, MemoryCare Corporation, which provides therapy services to with dementia. (2010 - present)

Consultant for Communication Bridge research study at the Cognitive Neurology and Alzheimer's Disease Center at the Northwestern Feinberg School of Medicine and receives reimbursement for consultation time and treatment sessions for individuals with PPA. (2013 - present)

Received honoraria from KSHA for this presentation

Copyrighted Materal: Do not copy or distribute.

Presentation Outline

• Dementia syndromes vs Neuropathology

• Care Pathway Model to care

• Impact of the diagnosis on the family/caregiver

• Psychosocial Interventions

• Speech-Language Pathology Assessment

• Person-Centered Cognitive-Communication Strategies Memory Care Pathway

Language Care Pathway

Visuospatial Care Pathway

Behavioral Care Pathway

• Case Study


Learner Outcomes

• Describe the Care Pathway Model to interdisciplinary care and how you might apply this in your healthcare setting

• Describe the importance of psychosocial interventions and how you may collaborate with a social worker in your setting to improve quality of life for individuals with dementia

• Describe person-centered assessment and how to identify meaningful goals when developing a plan of care for persons with dementia

• Describe 5 evidence-based approaches for the treatment of dementia and how to integrate personally relevant stimuli into the plan of care


© MemoryCare Corporation. These materials are not to be reproduced or distributed without prior written consent.

Holistic Approach to Intervention

A diagnosis of dementia can cause:

•A sense of isolation; social withdrawal

•Decreased participation in meaningful, purposeful activities

•The loss of dignity and sense of self

•The loss of independence and safety

Dementia

• Decline from prior level of functioning in cognition, emotion, and/or behavior

• Progressive worsening over time

• Interferes with independence and daily activities

• There are many causes of dementia

Dementia: An Umbrella Term


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Dementia Syndrome vs Neuropathology

• Dementia syndromes are the clinical presentation of symptoms Alzheimer’s dementia – short term memory loss

Primary Progressive Aphasia – language

Behavioral Variant of Frontotemporal Dementia – changes in behavior and personality

Posterior Cortical Atrophy – visual agnosia

• All dementia syndromes are caused by an underlying neuropathology (protein) in the brain Alzheimer’s Disease (AD), FTLD-T, TPD-43

Short term memory

loss

Word finding, understanding speech,writing, and/or reading

difficulties

Visuospatial difficulties;

Visual Hallucinations

Behavioral &

Personality Changes

Your primary

symptoms

Are leading to problems in your daily

life

Repeat questions & stories; misplace

items; forget conversations, problems with

financial, schedule and medication

management

Difficulty with daily

communication, writing emails & letters; difficulty

reading emails or

novels

Trouble with spatial

orientation, driving;

“seeing” things in full view

Changes in

personality affecting

relationships and

decision-making; apathy that impacts

daily activities

Your neurologist may order additional tests to determine a possible cause of your symptoms: Neuropsychological testing (in-depth testing of all cognitive functions); MRI (to

look for brain atrophy or other cause)

You may receive a CLINICAL DEMENTIA DIAGNOSIS

Alzheimer’s dementia

Primary Progressive

Aphasia (type of

Frontotemporal dementia (FTD)

Posterior Cortical

Atrophy (PCA); Lewy Body Dementia

Behavioral Variant of

Frontotemporal Dementia

(bvFTD)

If your symptoms don’t affect daily life functioning, you may be diagnosed with MILD COGNITIVE IMPAIRMENT (MCI) OR if daily activities are affected, with dementia

Other clinical dementia diagnoses may include: Vascular dementia; Progressive Supranuclear Palsy (PSP); Corticobasal Degeneration (CBD); Parkinson’s dementia

Your neurologist may recommend additional tests to investigate the suspected underlying PROTEIN CAUSING your clinical symptoms: (1) Spinal Tap; (2) Amyloid PET Scan; (3) DAT scan;

Benefits of diagnosis: (1) Medications may slow progression if you have Alzheimer’s Disease; (2) You may qualify for research studies

Types of proteins

Alzheimer’s Disease

(Amyloid) FTLD-TAU FTLD-TDP

Lew Body: Alpha

Synuclein

Referral to research or resources

Research Programs

Social Work

Psychiatry Speech & Memory Therapy

Occupational Therapy

Physical Therapy


The CARE Pathway Model for Dementia (CARE-D)

Neurocognitive Profile

Psychosocial Assessment

Tailored Recommendations to the Person with

Dementia and Family

Morhardt, D., Weintraub, S., Khayum, B., Robinson, J., Medina, J., O’Hara, M., Mesulam, M., & Rogalski, E., (2015). The CARE Pathway Model for Dementia (CARE-D): Psychosocial and rehabilitative strategies for care in young-onset dementias. Psychiatric Clinics of North America, 38(2), 333-352.


SYMPTOMS: Forgets appointments, names, recent events, misplaces personal belongings; repeats the same questions.

MEMORY

SYMPTOMS: Poor judgment social disinhibition, loss of

empathy, new rituals and food preferences, apathy, inability to initiate, plan, organize, multi-task.

BEHAVIOR

SYMPTOMS: Poor word finding, word and sentence comprehension, spelling, reading, saying the wrong word or sentences with abnormal word order.

LANGUAGE

SYMPTOMS: Difficulty locating objects, route finding, judging distance, following lines while reading, cannot see the forest for the trees.

VISUOSPATIAL

NORTHWESTERN CARE PATHWAY MODEL

PATIENT

AND

FAMILY



Interventions: Maintain a routine, structure and consistency.

Referrals to speech and occupational therapies to assess and implement strategies at home such as calendars and other organizational systems to maximize independence

MEMORY

Interventions: Disclose diagnosis to friends and family to increase awareness, reduce embarrassment, avoid troubling social situations, legal/financial interventions, structured activity, family counseling

BEHAVIOR

Interventions: Speech therapy to assess and assist with maximizing communication, developing communication notebooks, “I have PPA” cards, identifying helpful augmentative communication devices.

LANGUAGE

Interventions: Occupational therapy to provide environmental suggestions to maximize independence. Low vision referrals to offer services to accommodate visual changes. – talking clocks, watches, cooking aids, audio books

VISUOSPATIAL

NORTHWESTERN CARE PATHWAY MODELSTRATEGIES

PATIENT

AND

FAMILY



Caregivers for Persons with Dementia

Who are they?

• More than 15 million Americans are caring for person with dementia

• Majority of persons with dementia are community-dwelling.

• Majority (85%) are cared for by family and friends

• Majority are spouse/partners

• Approximately 2/3 are women

• 34% are 65+

Alzheimer’s Association Facts & Figures, 2015 Copyrighted Materal: Do not copy or distribute.

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Caregivers

• Often called the invisible second patient

• Integral to quality of life

• Reasons for Caregiving

Love and reciprocity

Sense of duty, obligation, guilt

• Negative aspects of caregiving get the most attention

• 55-90% of caregivers experience positive effects Enjoying togetherness

Sharing activities

Feeling a reciprocal bond

Spiritual and personal growth

Increased faith

Feelings of accomplishment and mastery

Brodaty, H. (2009). Family caregivers of people with dementia. Diaglogues Clin Neurosci, 11(2), 271-228. Copyrighted Materal: Do not copy or distribute.

Impact of Dementia Caregiving on Well-Being: Finding Meaning

• Dynamics of meaning making within the caregiver role have been explored as a way of coping.

• Caregivers who find meaning through caregiving may experience less burden.

Farran et al., 1997


Caregiving: Relational and Multidimensional

“The experience of care partners in cases of dementia is multidimensional and includes many factors relevant to the culture, context and dynamic in each individual relationship, such as:

• support structures available within the family and the community,

• personal coping resources,

• historical relationship

• the meaning that individuals ascribe to their experiences.”

Kindell et al. (2014). Living with semantic dementia: A case study of one family’s experience. Qualitative Health Research, 24(3), 401-411. Brodaty, H. (2009). Family caregivers of people with dementia. Diaglogues Clin Neurosci, 11(2), 271-228.


Timeline and Phases of Illness

From Rolland, J.S. (1984) Copyrighted Materal: Do not copy or distribute.

Initial Crisis Phase

Key Individual/Family Tasks

• Learning to cope with symptoms • Establishing working relationships

with health care team • Create a meaning for illness • Grieve loss of “normal life” before

illness • Gradually accept illness as long

term • Pull together as a family to cope

with immediate crisis • Develop flexibility toward future

goals.

Key Clinician Tasks

• Family is especially vulnerable at this phase

• Health care professionals have enormous influence over a family’s sense of competence.

• Diagnosis disclosure is a “framing event”.

Rolland, J.S. (2012). Mastering Family Challenges in Serious Illness and Disability, in Walsh. F. (Ed.) Normal Family Processes (4th Ed. pp. 452-482). New York: Guilford Press.


Chronic Phase

•Time span after diagnosis

•“The long haul”

•“Living in limbo”

•An exhausting problem “without end”

•Normal ambivalence / escape fantasies / survivor guilt



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Chronic Phase

Key Individual/Family Tasks

• Come to grips with long-term changes

• Devise an ongoing coping strategy

• Maintain semblance of a normal life during heightened uncertainty

Key Clinician Tasks

• Help families develop new priorities within a “new normal”

• Help families maintain sense of autonomy

• Normalize emotions of ambivalence and loss to reduce feelings of blame, shame and guilt



Living with Ambiguity • Uncertainty about the future

• Previous ideal of a close relationship – with clear roles - must change.

• Losing a person while they are still here (Boss, P., 1997)


What Helps?

State of the Science • 30 years of 200+ intervention studies

• 7 meta-analyses, 17 systematic reviews suggest a strong evidence exists for translating research into practice

Family Caregiver Intervention Treatment Modalities • Professional Support

• Psychoeducational

• Behavior management/skills training

• Counseling/psychotherapy

• Self-care/relaxation techniques

• Environmental redesign

• Multicomponent

Gitlin, L., et al. (2015). Translating evidence-based dementia caregiving interventions into practice: state of the science and next steps, The Gerontologist, 55(2). Copyrighted Materal: Do not copy or distribute.

Evidence based caregiver interventions

Outcomes • Increased caregiver knowledge and

understanding of memory problems

• Decreased caregiver stress and depression

• Better behavioral symptom management

Limitations • Lack of diversity / generalizability

Demographic subgroups underrepresented • Men, minority populations, rural, long-

distance, multiple carers

Non-Alzheimer’s dementia not represented

• Long-term effectiveness

Gitlin, L., et al., 2015; Gould, Hughes, O’Keefe, & Weiner, 2014; Brodaty & Arasaratnam, 2012


Person-Centered SLP Assessment Approaches for People with Dementia


What is the purpose of your assessment?

Are you part of a diagnostic team to evaluate and provide a diagnosis for your client?

Or….

Is the client/family coming to you out of concerns about their impairments or dementia diagnosis in hopes that you can help them to participate more fully in daily life?


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Key Principles of Person-Centered Assessment

• The person and family members are at the center of the care

• Think beyond the diagnosis and impairments: who is the person underneath?

• Do things WITH your client, not TO your client

• What are your client’s main concerns? How are their impairments impacting daily activities?

• What are the family member’s concerns?

• What are their areas of interests?

• What are their preserved strengths? (rather than focusing solely upon the weaknesses)

• Establish a profile of functioning across domains

• Plan for each client individually


Time to test your partner!

1. What is today’s date?

2. Where are you right now?

3. Count backwards from 100 by 7’s.

4. Name as many words that you can think of that start with the letter F.

5. Raise your hand, touch your nose, then point to me.


Reactions

•How did you feel being tested?

•How do you think it would feel if you have just been diagnosed with a fatal and devastating disease, and the first thing your clinician does is test you?

•From the questions asked:

Can you answer any of these questions… • How are the person’s impairments impacting their daily life?

• Can they participate in the activities they enjoy?

• How is the person coping with their diagnosis? Copyrighted Materal: Do not copy or distribute.

It’s Time to Flip the Rehab Model! (M. Bourgeois, 2015)

• Put the client and family members at the center of the evaluation

• Identify their concerns

• Administer standardized tests or subtests of standardized tests to further assess areas concern (e.g., Asking repetitive questions, administer story retell test of ABCD to

assess short term episodic memory loss)

• All goals are then written to address their concerns and are focused upon personally relevant stimuli

• CLIENT-DIRECTED, NOT CLINICIAN-DIRECTED Copyrighted Materal: Do not copy or distribute.

Other Assessment Considerations

1. Speech-Language Therapy is a team sport, and the care-partner/staff members are essential players

2. Use dynamic assessment (e.g., teach-test-retest methods, trial therapy) and objectively document responsiveness to each therapeutic technique or procedure (Bourgeois & Hickey, 2009)

3. Ask questions related to personally relevant topics (“Can you tell me about your grandchildren?” or “What are some of your favorite foods?” instead of, “Name as many animals as you can in one minute”)

4. Determine new strategies that will be needed as symptoms progress

5. Complete education and counseling throughout the evaluation

6. Determine if standardized testing is needed

• Is this evaluation part of the diagnostic process?

• Does insurance reimbursement require standardized testing?

Please do not copy/distribute without permission


6 Steps for a Person-Centered Assessment

•BUILD RAPPORT: WHO IS YOUR CLIENT AS A PERSON?

•OBSERVE COMMUNICATION/ENVIRONMENT

•INTERVIEW: ASK YOUR CLIENT/FAMILY MEMBERS ABOUT THEIR

CONCERNS/FRUSTRATIONS

•DETERMINE IMPACT ON LIFE PARTICIPATION IN DAILY ACTIVITIES

•EDUCATE AND COUNSEL

•ADMINSTER SHORT STANDARDIZED ASSESSMENT, IF NEEDED


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A quick thought about staging….

• Does assigning a stage to your client help you with the following questions: Understanding who they are as a person?

Understanding how their unique set of strengths/weaknesses are impacting life participation in desired activities?

Understanding their family dynamics, level of support, and how these variables will impact their participation in therapy?

Understanding how they are coping with their diagnosis and their motivation to participate in therapy?

These are the critical questions that need to be answered to develop a person-centered plan of care

and tailored goals to meet individual needs.

Does staging someone help to answer these questions?


Functional Standardized Tests: Cognition


Functional Standardized Tests: Language


(A Kagan, N Simmons-Mackie, JC Victor, 2011)

Assessment for Living

with Aphasia (ALA)

Communication Activities of

Daily Living – 2nd Edition (CADL-2)

(CADL-2; Holland, Frattali, & Fromm, 1999)


Other resources


Goal Writing Always include the individual’s and family’s input

Goals should be individualized and should focus on functional outcomes

Goals should be realistic; may need adjust the level of cueing as the disease progresses so that goals can be met

Example Goals for Aphasia:

PWA will retrieve names of 9/10 personally relevant people and places in response to open-ended questions with use of communication wallet, given minimal verbal and gestural cues, to increase ability to participate in conversations with family and friends.

PWA will pronounce personally relevant multisyllabic words with 80% acc during structured tasks, with use of syllable segmentation, orthographic cues, and verbal fading cues hierarchy for apraxia of speech, provided with moderate cues from spouse to increase ability to participate in conversations with family and friends.



Cognition Goal Examples

• Individual will plan weekly menu with use of weekly menu template and with organization of simple recipes that she can still prepare, with 90% acc, given min verbal cues from ST, to increase ability to independently prepare meals.

• Individual will locate 3/3 functional objects around the home with use of organizational strategies/external memory aids, given min verbal cues, to increase independence in ADL function.

• Individual will sequence 3/3 steps to operate cell, TV remote, and computer with use of visual memory aids, given min verbal cues, to increase sequencing ability for operating complex devices around the home.

• Individual will decrease frequency of perseverative questions regarding daily schedule to <3x/session x 1 week with use of memory wallet, given min verbal cues, to increase functional recall regarding daily schedule and activities.


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Person-Centered, Evidence-Based Treatment Approaches

•Memory Care Pathway

•Language Care Pathway

•Visuospatial Care Pathway

•Behavioral Care Pathway



Treatment Approaches

• Impairment-based Approach

Focuses improving individual’s weaknesses

Drill-based

Clinician-directed

• Life-Participation Approach (Simmons-Mackie et al, 2001) “LPAA emphasizes the attainment of reengagement in life by

strengthening daily participation in activities of choice.”

Takes advantage of individual’s strengths

Focuses upon functional activities that are meaningful to the individual

Client-directed

Life Participation Approach to Treatment

Interventions are person-centered and focus on much more than

the individual’s impairments, also taking into account participation

in meaningful life activities and how the impairments impact the

individual’s identify and feelings.

Kagan, Aphasiology 2008 Please do not copy/distribute without permission


Activity

Make a list of 10 personally relevant words that are important to you in daily conversations


Activity


Toss the Work Books!

• Join the “Toss the Workbook” movement!

• Before you can apply the person-centered, Care Pathway model to your setting, you must be actively using the established evidence-based approaches for people with dementia

How else will we get buy in for the services we can provide?


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Interventions: Memory Care Pathway

A Quick Overview:

Evidence-Based Interventions for Amnestic Dementia

Creation of graphic and visual cueing systems: e.g., visual memory aids, memory books, and memory wallets—to help individuals recall any type of information that is important to them (Bourgeois, 1990).

Use of spaced retrieval training (SRT) to promote use of graphic cueing systems (Camp & Stevens, 1990).



A Quick Overview:


• Vanishing cues: technique in which cues or prompts are gradually faded in relation to the learning progress (Sohlberg, Ehlhardt, & Kennedy, 2005)

• Errorless learning: memory intervention technique where clinicians use cues or instruction to prevent or reduce the likelihood of individuals making mistakes during learning trials (Clare & Jones, 2008)



A Quick Overview:


• Environmental Modifications: Assessing lighting, color schemes, flooring, furniture and hangings, and noise/sound — and then make the appropriate adaptations so the individual can function more independently and safely (Bruce, Brush, Sanford, & Calkins, 2013).

• Communication Strategies: Training family members and caregivers to use positive communication patterns, such as avoiding questions that rely on short-term memory and asking choice questions instead of open-ended questions.



Intervention Continuum through all Stages of Alzheimer's Dementia

Early Stages

Late Stages

Cognitive Training

Middle Stages

Compensatory Strategies Family/Caregiver

Education & Training

Spaced Retrieval Training

Errorless Learning

Vanishing Cues

Graphic Cueing Systems

Electronic Memory Devices

Memory Stations

Strategies to increase initiation, organization, and sequencing

Initiate care partner training on recommended strategies

Environmental modifications


Adaptive Equipment

Bathing/Dressing

Visuospatial strategies

Communication strategies

Managing difficult behaviors

Increased reliance on caregiver to help implement strategies

Communication strategies


Managing difficult behaviors

Strategies to address other common problems: (swallowing, fall prevention, functional mobility, incontinence, perceptual deficits)

Predominantly caregiver training

Link with External Resources

1 2 3



Single most effective way to facilitate functional recall: • Signs

• Written reminders

• Schedule Board

• Memory Wallet

• Memory Book

• Visual sequencing aids

• *Must be combined with caregiver education and training to be effective (Egan et al, 2010)

The use of written or electronic aids to prompt memory has been associated with increasing: Prospective memory (Oriani et al. 2003)

Positive ADL learning outcomes (Lancioni et al., 2010)

Reduction of repetitive questions (Hopper et al., 2013)


Graphic Cueing System: Memory Station

• Creation of Memory Station: Schedule board

Large display clock with date

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Graphic Cueing System: Memory Station


Graphic Cueing System: Reminder Board

Graphic Cueing System: Visual Aid


Graphic Cueing System: Visual Aids


Graphic Cueing System: Visual Aid


Graphic Cueing System: Memory Aids


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Memory/Communication Wallet Memory/Communication Wallet



Memory Book: Reminiscence Therapy


Memory Book: Visual Supports Creative Arts Discussions History Discussions


Visual Sequencing Aids: Technology, Recipes Visual Sequencing Aids for Volunteer Work


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Visual Sequencing Aid: Meal Prep


Visual Sequencing Aid: Medications


Visual Aid: Grocery List Template



Electronic Memory Aids

•Examples: Large display clock with date

Automatic pill dispenser

Memory Phone

Object locator


Electronic Graphic Cueing Systems • Reminders/Alerts

• To Do lists

Listastic

Personal Assistant

ListPro

MindMate

• Short term episodic memory

DayOne

Momento

• Memory book

PicCollage

Memory Garden

MindMate

• Word recall

FlipCard Pro


Electronic Graphic Cueing Systems

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Electronic Memory Books

Story Creator App






Simulated Presence Treatment

Treatment focuses upon recording and re-playing videos of familiar persons or persons in position of authority (e.g., physician), to elicit desired behavior:

• Bathing • Exercising • Decreasing risk of elopement • Discussing events from the

past to promote engagement • To provide comfort or

reassurance • To stimulate conversation

between two people Copyrighted Materal: Do not copy or distribute.


Care Partner Training: Take the Focus off of Short Term Memory

Avoid questions or statements that

rely on short term memory

DON’T SAY: DO SAY:

Do you remember me? Hi! I’m your physical therapist, Becky. It’s so nice to see you.

What day is it today? I can’t believe it’s already Thursday!

What did you do today? How’s it going?

Is that a new sweater? That sweater is so pretty on you. I don’t remember it.

What did you have for lunch today?

How was lunch today?

(Strauss, C.J., 2001) © MemoryCare Corporation. These materials are not to be reproduced or distributed without prior written consent.

Language Care Pathway

• Review of Primary Progressive Aphasia

• Person-Centered Treatment for Communication

• Reading/Writing Strategies

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Primary

Progressive

Aphasia

Mesulam, 2001, 2003, 2009

The impairment will get worse over time,

since its caused by a neurodegenerative disease

Impairment is prominent in a single domain

(language) with relative sparing of other domains

early on (e.g., memory, personality and perception)

a language impairment


PPA-L

(logopenic)

Preserved Grammar Preserved Word Comprehension

Impaired word-finding (or

retrieval)

Impaired repetition*

PPA-G

(agrammatic)

PPA-S

(semantic)

Impaired Grammar Preserved Word Comprehension

Impaired word-finding

Preserved Grammar Impaired Word

Comprehension Impaired word-finding

Mesulam et. al Neurology, 2009

PPA comes in different flavors


Clinical Syndrome

Neuroanatomic Features

Neuropathologic

Features

Established the anatomical selectivity

of PPA for the left hemisphere

perisylvian language network

Identified PPA as a clinical dementia that

was unique from clinical Dementia of the

Alzheimer’s Type (DAT) and from

aphasias caused by stroke

Identified neuropathologic

features associated with PPA are

variable

Early PPA Research

Clinical

Dementias

PPA bvFTD

DAT

FTLD-T AD



Pathology

Anatomy

Clinical Subtypes

Clinical Syndrome

Progressive language impairment

PPA-S

(semantic)

PPA-G (agrammatic)

PPA-L (logopenic)

TDP-43 FTLD-T AD

MR Pictures from Meuslam 2009; Pathology Pictures courtesy of E.Bigio & Hatanpaa, K 2008 J Neuropath

PPA Subtypes & Clinico-pathologic correlations



Pharmacological interventions for

individuals with PPA

No FDA-approved disease modifying treatments for PPA

Past clinical trials for individuals with PPA: • Bromocriptine [Parlodel, Cycloset] (Reed et al. 2004)

• Dopamine agonist, used in Parkinsons and shown to improve speech production in stroke-induced aphasia cases

• Galantamine [Razadyne] (Kertesz et al. 2008)

• A cholinesterase inhibitor acts to increase acetylcholine in the brain

• Memantine [Namenda] (Johnson et al. 2010, Boxer 2013)

• Acts on the glutamatergic system by blocking NMDA receptors

Future pharmacological interventions will need to target specific forms of disease based on the suspected neuropathology



Interventions: Language Care Pathway

• Self-cueing strategies:

Semantic circumlocution

Phonemic self-cueing

Writing

Gestures

Visualization

• Reinforce positive self-cueing or word retrieval strategies that individual and care partner are already using

• Should others fill in the word for people with PPA or other dementia syndromes?



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Lexical Retrieval/Motor Speech Production Program

Rehearsal of Personally Relevant Words

PWA should make a list of words or phrases that are important and used on a daily basis, especially those that are difficult for them to retrieve or pronounce

Family members, friends, political figures

Street names, stores, restaurants, places traveled

TV shows, sports terminology

Words related to their hobbies: gardening, woodwork, exercise, music, theater

Personal facts: address, phone number, email address, date of birth, last 4 digits of social security number

Household objects


Example of Personally Relevant Word List



Lexical Retrieval of Personally Relevant Words

• Rehearsal Program

Home program designed to increase the individual’s lexical retrieval of words that they frequently use during daily conversation



Lexical Retrieval: Flashcards


Use of Writing Treatment to Facilitate Lexical Retrieval

Personally Relevant Word Rehearsal:

Writing practice to facilitate spelling and retrieval


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Examples of writing practice


Examples of Writing Practice


Motor Speech Production of Personally Relevant Words

• Strategies to increase pronunciation of personally relevant multisyllabic words

• Syllable segmentation

• Phonetic orthographic cues

• Fading cues hierarchy (a modified version of Rosenbek’s 8 steps for apraxia of speech; Rosenbeck, 1973)

• Rhythmic and Intonation strategies

• Modified Version of Melodic Intonation Therapy



Motor Speech Production






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Quizlet (free) • Good audio cues

• No picture cues on free version

FlipCards Pro ($3.99) • More difficult to initiate audio cues

• Allows you to insert photographs

Apps to Practice Word Rehearsal






Script Training

• Script Training

• Individual and care-partner are trained to formulate and rehearse scripts, to increase ability to speak via telephone, tell stories or jokes, order food at a restaurant, say prayers, or explain their condition to others (Youmans et al.,

2005)



Script Training


Script Training

No rehearsal.

PWA reads off script at dinner and is able to say prayer much

more fluently.


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Script Training

Additional Examples of Script Topics • Talk to a family member or friend over the telephone and

in other environments (e.g. with grandchildren)

• Order food at a favorite restaurant/drive-thru, schedule an appointment, or ask for directions over the telephone

• State personal information or biographical facts

• Explain the condition of “aphasia/PPA” and asking listeners to be patient

• Telling jokes or stories

• Giving a lecture or speech

• Saying prayers


Script Training

Conversation Scripts How to make:

• Put all scripts in page protectors in 3-ringed binder

• Can also laminate and include in Communication Wallet

• Best if typed up and printed out (but can also be handwritten)

• Type up individual’s joke, story, or responses

• Try using landscape instead of portrait

• Try to keep one sentence per line.

• Assess most appropriate font size/spacing


Script Training

Use of Technology for Script Rehearsal: VAST http://www.speakinmotion.com/

What is VAST?

“VAST is an innovative application of video technology to facilitate and improve communication abilities for speech-impaired individuals. Following close-up

video of mouth movements allows these individuals to speak full sentences. The simultaneous combination of visual, auditory and, in some cases, written cues,

allows these individuals to readily produce speech. VAST facilitates live communication and individualized, mobile speech practice.”


Personal Picture Description Task

Structured description of personally-relevant pictures as a home exercise. Content may be used in daily conversations.

•Jonamac’s Apple Orchard

•Gala apples were ripe.

•Apple cider slushies

•Pumpkin donuts

•Hayride

•Corn maze



Communication Wallet

Portable word- or picture-based aid to facilitate daily conversations

Helpful apps: • Microsoft PowerPoint




Determine appropriate font size • Can PWA easily read the information?

Determine how much information to include on each page

Decide on content • Should be words, phrases, or sentences that individual

may need to frequently communicate in conversation


http://www.speakinmotion.com/

http://www.speakinmotion.com/

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How to use

• PWA can use for reference during conversation when unable to think of a word or question.

• PWA can study particular names before going to a social event

• Communication partner can remind PWA to pull out wallet to help find missing word


PPA Card - Generic


PPA Card - Personalized


PPA Card: Personalized


Communication Boards/Books • Word or picture-based aids to facilitate daily conversations in the home

Helpful Apps: Pic Collage


Copyrighted Materal: Do not copy or distribute. Copyrighted Materal: Do not copy or distribute.

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Communication Board


Communication Boards – Posted on Wall


Examples: Communication Boards


Communication Strategy: Drawing


Use of Smart Phone/Tablet Pictures • Use of Smart Phone/Tablet Pictures

Develop system of taking pictures during daily activities; integrate pictures into daily conversations

Pictures from photo stream Story Creator App Please do not copy/distribute without permission


Electronic Communication Aids: Pictures of daily activities on iPhone/iPad


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Speech Generating Devices • Must consider the following factors:

• Individual’s motivation to use an AAC device

• Individual’s fine motor and sequencing skills (Can he successfully operate a computer, TV remote or cell phone?)

• Individual’s level of family support, as someone will be needed to help individual program and effectively use the device as the disease progresses

• Out of pocket cost for the individual

• Trialing the use of a device in the individual’s home environment during functional situations

• MULTI-MODALITY APPROACH: Consider using different types of low-tech vs. high-tech communication aids in different contexts



Speech Generating Device

GoTalk20+ ($200)

Simple device

Easy to use

Allows user to record his/her own voice for 100 short utterances.

5 levels, with overlays

Computer software for images


Speech Generating Apps • GoTalk Now app ($79.99)

• For the iPad

• Ability to insert personal pictures and record own speech


Speech Generating Apps Lingraphica SmallTalk


Speech Generating Apps

Story Creator by Alligator Apps (free)

For the iPhone and iPad

• Simpler version of Pictello

• You can create a sequenced, narrated slideshow using your own pictures

• Unique feature: adding videos

• No text to speech option

• Displays spectrogram of your recorded messages

• Easier to program compared to Pictello

• Fewer editing options than Pictello


Speech Generating Apps Story Creator


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Scene&Heard ($50)

(for the iPhone and iPad)

• Users can import their own photographs to create scenes

• Users can then record stories and messages to go along with different parts of the picture

• Easy to use and navigate

• Great for customized communication needs



Scene&Heard



Locabulary ($130)

(for the iPhone & iPad)

• Allows users to combine location and vocabulary to communicate

• Can use current GPS location to associate with a category

• NOT picture based

• Requires user to construct own sentences

• Can use pre-stored messages

• Can record own voice Copyrighted Materal: Do not copy or distribute.


Locabulary


Auditory Comprehension

• Facilitating auditory comprehension:

Training communication partners to use the following strategies:

• eliminating distractions

• simplifying sentence structure

• slowing rate

• increasing use of nonverbal cues

• use of written or picture cues



Auditory Comprehension: Writing Key Words


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Agraphia Strategies

- Use of speech recognition and word prediction features to facilitate spelling

Use of spelling or grammar check apps to facilitate functional writing tasks

Written aids/templates for emails or lists



Alexia Strategies

• Use of speech recognition apps to look up pictures/word descriptions to facilitate single word comprehension

• • Use of digital books with

embedded links to Wikipedia or a Dictionary to increase single word comprehension

• Use of audio books + paper-back book for increased comprehension of novels



Number Strategies

Use of written aids to facilitate reading/writing of phone numbers and addresses or taking phone messages

Written aid for TV/radio stations

Templates for check-writing

Tip calculator apps



Applications to Other Dementia Syndromes • Considerations when applying communication strategies: Alzheimer’s dementia

• Early onset AD often has prominent aphasia in early stages

• Late onset AD; communication deficits typically present in moderate-severe stages

• Due to amnestic symptoms, involvement of family or caregiver will be critical for generalization of strategies

• Focus on activity/participation-based strategies

Behavioral Variant of Frontotemporal Dementia (bvFTD) • Due to decreased insight into deficits, involvement of family or caregiver will be critical for

generalization of strategies

• Focus on activity/participation-based strategies

Corticobasal Degeneration (CBD) • Consider intelligibility strategies if dysarthria is present

• Education regarding dysphagia due to early onset of motor symptoms

• Start formulation of communication aids quickly

Progressive Supranuclear Palsy (PSP) • Consider intelligibility strategies if dysarthria is present

• Education regarding dysphagia due to early onset of motor symptoms

• Start formulation of communication aids quickly

• Consult with Occupational Therapy regarding visual deficits and how they may impact communication aids


Interventions: Visuospatial Care Pathway

•Refer to an Occupational Therapist who specializes in low vision

• SLP can also assess:

• Lighting

• Color schemes

• Flooring

• Furniture and hangings

• Noise and sound

*ECAT- Environmental and Communication Assessment Kit (Brush, J., Calkins, M., Bruce, C., & Sanford, J., 2012)


Misplacement of Functional Objects

Strategies:

Decluttering

Use of organizers

Clear labeling

Increased contrast

Establishing location for specific items

Vanishing cues to implement use of system


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KEYS


Interventions: Behavioral Care Pathway

Treatment should Focus upon

Care Partner Training:

•Don’t reason or argue

•Redirect

•Distract

•Validate

•White Lie

•Comfort .

(Coste, J.K., 2003) Copyrighted Materal: Do not copy or distribute.

Behavior Log

•A great tool for determining what may be triggering a challenging behavior

•Record the behavior, the time of day, exact location, description of environmental factors (odors, sights, sounds)

•Look for a pattern after a week of recording the behavior


Use of Montessori Approaches to Increase Participation in Meaningful Activities

•Modifying activities/hobbies individual enjoys so participation is still possible

•Music, Art, Theater, Dancing

•Intergenerational activities

•Pet therapy

•Reminiscence


Importance of Meaningful Activities • Water color painting

• Playing piano

• Gardening

• Cooking

• Hiking in mountains

• Golfing

• Mosaics

• Sudoku

• Water aerobics

• Carpentry

• Ballroom dancing

• Pets

• Movies – Documentary festivals

• Travel

• Watching sports

• Volunteering at food pantry

• Raising sheep

• Surfing

Building chemical plant model


Meaningful Activity Example

• Playing the piano


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Meaningful Activity Example

• Water color painting


Implementation in Your Setting

YOU can take a leadership role in helping to implement an interdisciplinary team

in your setting!

“Rebrand” the role of the SLP

We do more than just treat swallowing!

If we don’t take action in helping people with dementia across

healthcare settings, who will? Copyrighted Materal: Do not copy or distribute.

Implementation in Your Setting Arguments:

• Productivity requirements don’t permit enough time to start this type of program for frequent collaboration with other professionals

• It’s too difficult to communicate with family members; they are never around when I am there

• It’s too hard to develop a relationship with the nursing staff; they are too busy and there is a lot of turnover Copyrighted Materal: Do not copy or distribute.

Establish Monthly Inservices

How to structure a 30 minute inservice:

5 minutes: Summarize the role of the SLP and the types of treatment we can provide

10 minutes: Elaborate upon Cognitive-Communication Strategies for people with dementia

5 minutes: Review positive communication strategies for people with dementia

5 minutes: Provide a “case study” – example of a person you have worked with in this setting

5 minutes: Q & A


Establish Weekly “Rounds”

•Encourage your setting to start a weekly “Rounds” to increase collaboration between disciplines and coordination of care

•For each case: Review diagnosis, psychosocial variables, progress in

therapy

Other referrals or resources that are appropriate


Case Study: Ben (Memory Care Pathway)

History

• 65 year old man former stockbroker handling financial accounts with 2-3 year history of mild progressive decline in cognition.

• Married to wife Diane for 13 years

• MMSE 30/30

• Continues to be active, rides bike, plays tennis, takes classes.

• Mood, appetite, sleep - good

• Unable to manage finances – wife has taken over for the past 2 years

• Wife maintains active lifestyle and resents the loss of their future plans as a couple.

• 2nd marriage of 13 years

• No children – Ben was a ‘bachelor’ until age 50


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Symptoms • Hygiene decline –

does not change underwear, wash hair or shower without reminders

• Difficulty navigating while driving

• Turns on the AC but leaves windows open

• Used to play bridge, but can no longer “keep up”

• Does not eat lunch when wife not home

• Returns with groceries but forgets to unpack items and put them away

• Got mixed up about the set-up of wife’s daughter’s studio apartment

• Forgot the plays he had seen in the prior 6 months.

• Misunderstood a question friend had asked and answered in a slightly tangential way

• Mixed up words – called Lake Michigan an ‘ocean’ ; called a fork a ‘spoon’.


Partner Activity

What evidence-based interventions would you use?

Write one person-centered goal for each intervention:


Interventions: Ben (Memory Care Pathway)

Social Work

• Education and support for patient and wife

• Counseling for wife on loss of reciprocity in relationship and future plans

• Encourage wife to seek out emotional support

•Reinforce helpful communication strategies

• Encourage driving evaluation

• Help evaluate decision-making, judgment and safety over time

• Help prepare wife to take on more responsibility over time while balancing her own needs



Speech-Language Pathology • Hygiene:

Placed visual aid on laundry basket “DIRTY LAUNDRY” and placed basket in walk-in closet where he changes clothes each day

Made visual sequencing aid (laminated) for shower, with reminders for each step

Established “bathing routine” for Mondays/Wednesdays/Fridays. Spouse trained to place sticky note visual aid on his bathroom mirror on days he needs to shower

• Air Conditioning:

Bright green visual aid placed on wall next to A/C control, which states: “GO CLOSE WINDOWS IMMEDIATELY”. Reminder also written on dry erase board in kitchen



Speech-Language Pathology • Groceries & Meal Prep

Memory Station is created in the kitchen

Ben’s spouse trained to display large visual memory aid in memory station on days he is going shopping that states: REMEMBER TO PUT AWAY GROCERIES

Visual aid reminders also placed on fridge and pantry

Ben’s spouse trained to use dry erase board for daily schedule and reminders

Each day, she writes instructions as to where she is, when she will return, and what Ben should eat for lunch

Reoccurring alarm is set for noon each day on Ben’s cell phone, with the reminder to eat lunch



Speech-Language Pathology • Memory/Communication Wallet

Functional information for daily activities

List of plays he has seen, with short description

Lists of words by category that he has trouble retrieving

Information and diagram regarding layout of his daughter’s apartment

• Spaced Retrieval/Errorless Learning to increase Ben’s ability to automatically refer to his wallet for information

• Spouse education on communication strategies

How to prompt circumlocution to facilitate lexical retrieval

It’s ok to fill in the words for him

Auditory Comprehension strategies – educated close friends and family members


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Questions?

Becky Khayum

[email protected]


References

• Beeson, P. , Hirsch, F., & Rewega, M., (2002). Successful single word writing treatment: Experimental analysis of four cases. Aphasiology, 16(4-6), 473-491.

• Beeson, P.M., King, R. M., Bonakdarpour, B., Henry, M.L., Cho, H & Rapcsak, S.Z (2011). Positive effects of language treatment for the logopenic variant of primary progressive aphasia. J Mol Neurosci, 45(3), 724-736.

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Special thanks to the research participants and their family members for their time and commitment to research, without

them none of this work would be possible.

For more information please contact: [email protected] | [email protected]

NS075075; DC008552; AG13854

Acknowledgements



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