Brooke Hallowell April 2017 Why are we here? Empowering People with - - PDF document

Brooke Hallowell April 2017 1

Empowering People with Dementia and Those Who Care About Them: Evidence-Based Strategies to Enhance Meaningful Communication

Brooke Hallowell

Hallowell, B. (2017). Aphasia and other acquired neurogenic language disorders: A guide for clinical excellence. San Diego, CA: Plural Publishing. ISBN13: 978-1-59756-477-9

Why are we here?

Hallowell, B. (2017). Aphasia and other acquired neurogenic language disorders: A guide for clinical excellence. San Diego, CA: Plural Publishing. ISBN13: 978-1-59756-477-9

What is neurodegenerative disease?

• Any neurogenic condition that progressively gets worse over time
• Neurodegenerative diseases impacting cognitive-linguistic abilities
• Any types of dementia
• Some forms of mild cognitive impairment (MCI)

Hallowell, B. (2017). Aphasia and other acquired neurogenic language disorders: A guide for clinical excellence. San Diego, CA: Plural Publishing. ISBN13: 978-1-59756-477-9

What are neurodegenerative conditions?

• A broad category of disorders entailing progressive changes in the

brain that result in progressive loss of neurological functioning

• Primary neurodegenerative conditions relevant to clinical aphasiology
• Mild cognitive impairment (MCI)

A condition of cognitive decline that is not consistent with normal aging

• Dementia

A constellation of symptoms including

Memory impairment One or more cognitive and/or linguistic impairments

• Primary progressive aphasia (PPA)

The progressive loss of linguistic abilities in contrast to relatively intact cognitive abilities

Hallowell, B. (2016). Aphasia and other acquired neurogenic language disorders: A guide for clinical excellence. San Diego, CA: Plural Publishing. ISBN13: 978-1-59756-477-9

What is dementia?

• The criteria for the diagnosis of dementia
• Memory impairment
• One or more cognitive/linguistic impairments
• Most common symptoms
• Memory problems
• Behavior problems
• People with dementia develop different

problems with

• Attention
• Executive functions
• Critical thinking
• Language

Source: “Alzheimer's disease brain”. by Garrondo, derivative work:, license CC.0. Public Domain [modified].

Hallowell, B. (2017). Aphasia and other acquired neurogenic language disorders: A guide for clinical excellence. San Diego, CA: Plural Publishing. ISBN13: 978-1-59756-477-9

What are common forms of dementia?

Dementia

Alzheimer's disease (AD) MCI due to AD Vascular dementia Dementia with Lewy bodies (DLB) Parkinson's disease dementia Frontotempo ral dementia (FTD) Huntington's disease Korsakoff's Syndrome Creutzfelt- Jacob disease AIDS dementia complex Hallowell, B. (2017). Aphasia and other acquired neurogenic language disorders: A guide for clinical excellence. San Diego, CA: Plural Publishing. ISBN13: 978-1-59756-477-9

Brooke Hallowell April 2017 2

Is there such a thing as “reversible” dementia?

• The term “reversible” dementia is inaccurate and misleading
• By definition, dementia is progressive and gets worse over time
• The “progressive” nature of dementia is the key to distinguish it from other

non-progressive, dementia-like disorders

• e.g., Pseudo-dementia (or transient confusional state)
• Situations in which dementia-like symptoms may be noted despite the

absence of a true dementia

• Depression
• Dietary imbalances
• Vitamin deficiencies
• Drug effects
• Drug interactions
• Post-surgical states

Hallowell, B. (2016). Aphasia and other acquired neurogenic language disorders: A guide for clinical excellence. San Diego, CA: Plural Publishing. ISBN13: 978-1-59756-477-9

What are implications of an incorrect diagnosis of dementia?

• Unnecessary difficult emotional reactions
• f patients and caregivers
• Hardships related to untoward stigma on

a social level

• Incorrect prescription of medication and
• ther interventions
• Being deemed ineligible for coverage of

some crucial rehabilitation-related services

• Some third-party payers consider dementia

to be a “red flag” diagnosis

Source: “Holzfigur” By Counselling, licensed under CC0 Public Domain.

Hallowell, B. (2017). Aphasia and other acquired neurogenic language disorders: A guide for clinical excellence. San Diego, CA: Plural Publishing. ISBN13: 978-1-59756-477-9

What is mild cognitive impairment (MCI)?

• A condition of cognitive decline that is not typical of normal aging
• Etiologies
• Neurodegenerative disease
• Head injury
• Neoplasm
• Infectious processes
• Metabolic disorders
• Memory problems are the most common complaints of people with MCI

Hallowell, B. (2017). Aphasia and other acquired neurogenic language disorders: A guide for clinical excellence. San Diego, CA: Plural Publishing. ISBN13: 978-1-59756-477-9

What are some special challenges in identifying etiologies of language disorders?

• Age
• Socioeconomic status
• Cultural/linguistic background
• Health status
• Emotional health
• Social support

Acquired vs. Exacerbated Individual Differences Concomitant Conditions Multiple Etiologies

Hallowell, B. (2017). Aphasia and other acquired neurogenic language disorders: A guide for clinical excellence. San Diego, CA: Plural Publishing. ISBN13: 978-1-59756-477-9

Cognitive-Linguistic Intervention for people with MCI and Dementia

Introduction

• Cognitive intervention may lead to changes in the brain:
• Increased brain metabolism
• Increased cortical thickness
• Increased density of white matter tracts
• Best outcomes achieved when implemented early (when individuals

with MCI retain the capability to learn and apply strategies) (Jean et al., 2010; Stoot & Spector, 2011)

Brooke Hallowell April 2017 3

What we do not know

• Are specific interventions best for specific deficits?
• What outcome measures are most valid?
• Delivery: Is individual treatment better than group treatment?
• Dosage: How long should treatment sessions last? How long should

intervention programs last?

• Long-term effects: How long will program effects last?

What we do know

• Use repetition-based intervention that targets specific cognitive

domains

• Provide direct training of strategies and functional skills
• Empower clients with education regarding healthy aging and brain

habits

• Provide goal-oriented, strategic social opportunities that support

cognitive engagement

When developing a Cognitive Intervention Program…

1. Base your program on a framework that considers the impact of cognitive impairment on lives of affected individuals

Health Condition: MCI Key Element addressed Body & Functions Brain damage leading to impairments in memory, language, EF Target-oriented repetition-based intervention Activity Ability to complete specific tasks Selection and direct training of memory strategies Participation Fulfillment of social roles Provision of goal-

• riented strategic social

engagement Contextual factors Address modifiable risk- and protective factors Empowerment through education about healthy aging

When developing a Cognitive Intervention Program…

• 2. Purpose should be to improve cognitive and social functions
• 3. Include outcome measures that assess effects on function, activity

limitation, life participation restrictions and personal and environmental factors

Outcome measures

• Include a mix of objective and subjective outcome measures
• Objective measures: standardized tests evaluating cognitive domains
• Subjective measures: questionnaires of client/ family perception, mood, and

participation)

• Include pre-and post assessments

Typical Formats

Duration:

• 8-24 sessions (plus booster sessions in regular intervals after completion of

the training)

• 60-120 minutes

Components:

• Individual and group sessions
• Computer-based and paper-and-pencil tasks arranged in a “circuit”

Brooke Hallowell April 2017 4

Key Elements

• 1. Repetition
• Practice increases cognitive reserve
• More practice leads to more resilience against decline
• Target specific cognitive domains based on clients’ impairment profile to

strengthen preserved functions

Key Elements : Repetition (continued)

Computer-based intervention

• Cost effective
• Provides multiple training options
• Standardized intervention procedures
• Easily accessed
• Immediate, objective review of performance
• Gradual increase in difficulty (if it can be tailored)
• Most clients are familiar with computer, smart phone, tablets and have access to the

internet regularly

Computer-based intervention

• Most robust improvements on trained cognitive task (limited support for

generalization)

• BUT: participants often feel as they have improved cognition due to

training

• Self-reported cognitive improvements, positive feelings about ones cognition

may have important implications for everyday cognitive functions

Key Elements : Repetition (continued)

Key Elements : Repetition (continued) Computer-based intervention

Barnes & Colleagues (2009)

• Efficacy and feasibility of computer-based home training to improve speed and accuracy

in auditory processing in people with MCI Methods

• Tx group: Posit Science software 100 min/day x 5 days/week x 8 wks
• Control group: reading the paper online, listening to audiobooks, play computer games…
• Outcome measures: RBANS (Repeatable Battery for the Assessment of

Neuropsychological Status) Results

• No sig. differences on the RBANS between groups and pre-and post-test comparison
• But: overall trend for improvement in treatment and control group
• Importance of personally relevant treatment materials – individualized treatment

matters

Key Elements : Repetition (continued) Computer-based intervention

• SLP role:
• Formulate goals
• Select best activity
• Evaluate progress
• Make program modification

Key Elements : Repetition (continued) Computer-based intervention

• Questions to consider when selecting a program:
• Does the client have access to computer?
• What programs require internet access?
• Cost?
• What specific cognitive skills are addressed in the program?
• Support for program effectiveness?
• Can program be tailored to individual needs?
• Does program measure progress?
• Does program adjust the level of difficulty?

Brooke Hallowell April 2017 5

Key Element 2: Provide direct training of strategies

• Memory strategy training positively affects other domains of

cognition

• Frequent issue: prospective memory training (often addressed

through external memory aids)

• Clare et al. (2009; 2011)
• 8 wk x 1-hr/week introduced to a series of mnemonic strategies
• Participants were allowed to select one or two strategies for functional goals

relating to leisure tasks, household activities..) to implement in daily life

Memory Strategies

• External memory aids (teach use of calendars, smart phones…)
• Adapting the environment
• Method of loci (mentally linking a place with each item to be remembered)
• Mind mapping (links around a central word or idea are made using a

diagram)

• Visual imagery (mental images are created to facilitate the learning and

recall of materials)

• Categorizations and hierarchical organization (aimed at classifying

information to be learned by semantic category or by order of importance)

• PQRST (a way of helping yourself to remember something you are reading,

such as a newspaper article)

• Chunking (grouping information to be remembered)

Memory Strategies

Memory aids

• Smartphones and diary or calendar applications
• Diaries
• Notebooks
• Lists
• Alarm clocks
• Calendars
• Wall charts
• Tape recorders and Dictaphones
• Electronic organizers
• Pagers
• Pill reminder boxes for medication
• Sticky notes
• Photo albums
• Cameras

Memory Strategies

Adapting the environment

• Keeping a notepad by the phone to make a note of phone calls

and messages

• Putting essential information on a noticeboard
• Deciding on a special place to keep important objects like keys,

wallets

• and always putting them back in the same place
• Attaching important items to your person so they can’t be

mislaid, for example using a neck cord for reading glasses

• Labeling cupboards and storage vessels as a reminder of where

things are kept

• Labeling perishable food with the date it was opened

Memory Strategies

• Method of loci (mentally linking a place with each item to be

remembered) https://www.youtube.com/watch?v=PIg73ppoVZw

Mind maps:

• main idea crystallized

in a central image

• main themes branch
• ff from the central

image

• Use images, words or

both

• The branches form a

connected nodal structure

• Provide a structure

for your thoughts and visual representation

Brooke Hallowell April 2017 6

Memory Strategies PQRST

a way of helping yourself to remember something you are reading, such as a newspaper article. PQRST stands for:

• Preview – scan the information to get a general idea of the

content

• Question – identify some questions you want to be able to

answer after you have read it and write them down

• Read – read the material closely
• State – repeat the main points to yourself by stating them in

summary form

• Test – test your knowledge by seeing if you can answer the

questions you wrote down earlier

Key Element 3: Empowerment through Education

• Educate about life style factors that enhance development of

cognitive reserve

• Small discussion groups provide opportunity for social engagement
• Topics:
• Health benefits of physical activity and how to integrate it into one’s life
• Benefit of sleep
• Value of addressing changes in hearing acuity and communication strategies
• Principles of cognitive reserve
• Self- identify activities participants find enjoyable and relaxing, such as

listening to music or exercising, and develop goals and a plan to indulge in them.

Key Element 4: Provide goal oriented social

• pportunities that support cognitive engagement
• Decreased level of social engagement in people with

MCI

• High-quality social relationships contribute to good

health

• Reason for the group format
• Participants often comment on feeling reassured

about knowing other individuals with similar problems

What are memory books and memory wallets and how are they implemented?

• Collections of pictures, phrases, and

words associated with familiar people, places, and events that a person may have difficulty remembering (Bourgeois, 1992)

• Memory books

Often in the form of three-ring binders Contain photographs and printed words Can easily be edited and added to over time Photo albums may also be used

• Memory wallets

Typically plastic wallet inserts Contain emergency contact information, words that are important to remember, scheduling/calendar/appointment information, addresses, names, phone numbers, and associated pictures

• They are generally used with people

who have memory loss.

• People with language of generalized

intellectual impairment

• People with memory loss associated with

TBI

Hallowell, B. (2016). Aphasia and other acquired neurogenic language disorders: A guide for clinical excellence. San Diego, CA: Plural Publishing. ISBN13: 978-1-59756-477-9

What are memory books and memory wallets and how are they implemented?

Hallowell, B. (2016). Aphasia and other acquired neurogenic language disorders: A guide for clinical excellence. San Diego, CA: Plural Publishing. ISBN13: 978-1-59756-477-9

• The rationale for the use of

memory wallets and memory books

• People with dementia tend to retain

long-term memory abilities far beyond the time that they lose short-term memory abilities

• Repeated practice with personally

relevant stimuli helps to enhance access to associated facts, words, and names

Consider these prompts for conversation:

• Was your son here this morning?
• I see you had a corgi named Willie. He was so cute. I used to

have a corgi, too. What did you like best about having a dog?

Caring Memories Book

Hallowell, B. (2016). Aphasia and other acquired neurogenic language disorders: A guide for clinical excellence. San Diego, CA: Plural Publishing. ISBN13: 978-1-59756-477-9

• https://www.youtube.com/watch?v=5JjCwoJLoXM

Brooke Hallowell April 2017 7

Reminiscence

• Reminiscence allows an individual to recall and reflect on

personal life stories and experiences.

• Reminiscence activities target long-term memories that tend to

remain intact despite more advanced memory loss, particularly

• nes that have significant emotional meaning for individuals,

allowing an individual who may have severe short-term memory impairments to demonstrate a completely different level of competence

Steps to Create Memory Books/wallets

• 1. Compose a book or wallet containing pages of words, personal

photographs, and/or personally relevant sentences.

• 2. Use declarative sentences to represent the facts in the book.
• 3. Select facts to include based on memory failures that often occur.

BIOGRAPHICAL INFORMATION: NAME

Make sure to select a picture that the individual is able to identify. For some, this may be a picture from their youth. For others, it may be a more current picture.

M

My name is Dorothy.

BIOGRAPHICAL INFORMATION: AGE & BIRTHDAY

Make sure that if you include the individual’s current age, there will be someone there to update it as the individual ages.

My birthday is July 8, 1931.

BIOGRAPHICAL INFORMATION: PLACE OF BIRTH

Include information that is important to the individual. Make sure the individual identifies with the images

• chosen. This could be a

picture of the individual’s house, or an area of the town that has meaning.

I was born and raised in Athens, Ohio.

FAMILY INFORMATION

Again, make sure the individual is able to relate to the person in the

• picture. Choose pictures

with the help of the individual, family members, and friends.

This is my husband, Larry.

Brooke Hallowell April 2017 8

FAMILY INFORMATION

It is also appropriate to include individualized descriptions of pictures, if the individual has the cognitive and linguistic skills to benefit from

• them. Talk to the

individual and their family about personal thoughts and memories attached to pictures.

Larry and I got married on September 22, 1949. It was a beautiful day.

FAMILY INFORMATION

If multiple people are in a picture, it is often helpful to name the individuals in the order they appear in the photograph. If the individual has difficulty naming the people in the picture, repeated verbal cues combined with pointing may help.

Larry and I had three children: Julie, Rich, and Catherine.

FAMILY INFORMATION

It is often helpful to include pictures from the individual’s past (such as the previous picture) to aid in reminiscence and conversation. It is also important to include more current picture, which might aid in recognition of family members currently.

This is my daughter Julie, with her husband Chad.

MY SCHEDULE

Include activities the individual has trouble remembering, or those that are associated with behaviors.

• For example, if the

individual exhibits anxiety

• ver eating meals, including

them on the schedule may be a reminder about when and where these happen.

• Use words and/or pictures,

as appropriate. Also, include activities that are personally important for the individual (i.e., watching TV with friends) My Schedule 5:00 am – Wake Up 6:30 am - Shower 7:30 am – Eat Breakfast 10:00 am – Watch TV with friends Etc.

MY SCHEDULE

Some individuals may benefit from a page-by- page schedule. Be sure to continuously consider the individuals cognitive and linguistic abilities while setting up the memory book.

I wake up at 5:00 am.

TARGET AREAS

This type of page can be included if an individual is constantly asking questions regarding his or her medication. Including this page in the Memory Book may reduce that problem behavior.

This is the nurse’s station. I go here to ask about my daily medication.

Brooke Hallowell April 2017 9

HOW TO USE: POSSIBLE GOALS

Increase the duration of engagement in conversation Produce more utterances within a conversation Produce fewer perseverative utterances Produce fewer off-topic utterances and more on-topic utterances Engage in a single topic for a greater number of conversational turns Produce utterances of greater length and complexity Produce less ambiguous (more easily interpretable) utterances Provide more appropriate answers to questions about related content Improve naming and accuracy of naming of people and object depicted

and labeled

Demonstrate independent use of the aid

HOW TO USE: POSSIBLE ACTIVITIES

Looking at and reading one page at a time, stopping to converse

about the relevant context

Looking at a picture and using open-ended prompts, such as “tell

me about…,” or “what was it like when you...”

Elaborating on comments made by the person Asking for additional details Reading words phrases aloud or asking the person to do so Having the person show to the book to someone else and explain

content within it

Suggesting looking at or discussing content on the book to distract

the individual when he or she is sad or engages in undesirable behavior.

HOW TO USE: WHOM ELSE TO INVOLVE

Training staff and family members to use the book in supported

communication, with encouragement for positive aspects, enhances the likelihood of meaningful conversations in future interactions.

ACTIVITY

Identify positive and negative aspects of example memory books

according to:

Design (use of pictures, layout, portability of the book, etc.) Content (type of sentences, ability to link sentences to pictures, etc.) Specific ways to use example memory books as: Memory aids AAC materials Direct treatment materials (consider possible goals from previous slide) General supports to assist in meaningful conversation

What is spaced retrieval training (SRT) and how is it implemented?

• A method of learning and retaining

information by recalling the information over increasingly longer periods of time (Camp, Foss,

O’Hanlon, & Stevens, 1996, p. 196)

• The goal of SRT (Bayles & Tomoeda, 1997; Camp et al., 1996;

Cherry & Simmons-D’Gerolamo, 2005)

• To enhance accessibility to stored

representations By repeatedly activating them By making a person aware of them

• It targets implicit memory
• Unconscious and involuntary memory

Considered to be relatively robust in people with memory disorders associated with TBI and various forms of dementia

• Classified as an errorless learning method
• There are two basic forms of SRT (Morrow &

Fridriksson, 2006)

• Fixed-interval/uniform approach

The time between trials remains constant Helps transfer information into long-term storage

• Randomized-interval/adjusted approach

The time between trials is adjusted according to the individual’s performance Enhances long-term retention Featured in most of the relevant published literature

Hallowell, B. (2016). Aphasia and other acquired neurogenic language disorders: A guide for clinical excellence. San Diego, CA: Plural Publishing. ISBN13: 978-1-59756-477-9

The goal is to promote the best quality of interactions, and thus quality of life, with people who have dementia

• F Face to face
• Face the individual directly
• Attract the individual's attention
• Maintain eye contact
• O Orientation
• Orient the individual by repeating key words several times
• Repeat sentences exactly
• Give the individual time to comprehend what you say
• C Continuity
• Continue the same topic of conversation for as long as possible
• Prepare the individual if a new topic must be introduced
• U Unsticking
• Help the individual become "unstuck" when he or she uses a

word incorrectly by suggesting the word they are looking for

• Repeat the individual's sentence using the correct word
• Ask, "Do you mean…?"
• S Structure
• Structure the questions to give the individual a simple

choice to respond with

• Provide only two options at a time
• Provide options that the individual would like
• E Exchange
• Keep up the normal exchange of ideas we find in

conversation

• Begin conversations with pleasant, normal topics
• Ask easy questions that the individual can answer
• Give the individual clues as to how to answer
• D Direct
• Keep sentences short, simple, and direct
• Use specific, concrete nouns, rather than pronouns
• Use hand signals, pictures, and facial expressions

What is the FOCUSED program and how is it implemented?

FOCUSED is an acronym representing each of the following communication strategies (Ripich, Wykle, & Niles, 1995)

Hallowell, B. (2016). Aphasia and other acquired neurogenic language disorders: A guide for clinical excellence. San Diego, CA: Plural Publishing. ISBN13: 978-1-59756-477-9

Brooke Hallowell April 2017 10

What are Montessori approaches to dementia management?

• Initially developed for use with children in educational environments
• Theoretical foundations of the Montessori approach
• Enhances activation of intact intellectual and communicative activities
• Improves compensatory strategies through any means of supported

communication

• Multimodal sensory exploration is encouraged

Hallowell, B. (2016). Aphasia and other acquired neurogenic language disorders: A guide for clinical excellence. San Diego, CA: Plural Publishing. ISBN13: 978-1-59756-477-9

What are additional forms of programming to support people with dementia?

• The Breakfast Club (Boczko, 1994)
• An example of a social approach used in a

nursing home context

• The motivation for this approach

Long-term care residents with MCI and dementia

Are at risk for social isolation Have reduced opportunities for social interaction

• Adaptable to individuals and context
• The Savvy Caregiver Program (SCP)
• An example of a caregiver training

program

• A packaged program focused on

mediating caregiver stress through improved interactions with people who have dementia

Hallowell, B. (2016). Aphasia and other acquired neurogenic language disorders: A guide for clinical excellence. San Diego, CA: Plural Publishing. ISBN13: 978-1-59756-477-9

Empowering People with Dementia and Those Who Care About Them: Evidence-Based Strategies to Enhance Meaningful Communication

Brooke Hallowell

Hallowell, B. (2017). Aphasia and other acquired neurogenic language disorders: A guide for clinical excellence. San Diego, CA: Plural Publishing. ISBN13: 978-1-59756-477-9

Why are we here?

Hallowell, B. (2017). Aphasia and other acquired neurogenic language disorders: A guide for clinical excellence. San Diego, CA: Plural Publishing. ISBN13: 978-1-59756-477-9

What is neurodegenerative disease?

• Any neurogenic condition that progressively gets worse over time
• Neurodegenerative diseases impacting cognitive-linguistic abilities
• Any types of dementia
• Some forms of mild cognitive impairment (MCI)

Hallowell, B. (2017). Aphasia and other acquired neurogenic language disorders: A guide for clinical excellence. San Diego, CA: Plural Publishing. ISBN13: 978-1-59756-477-9

What are neurodegenerative conditions?

• A broad category of disorders entailing progressive changes in the

brain that result in progressive loss of neurological functioning

• Primary neurodegenerative conditions relevant to clinical aphasiology
• Mild cognitive impairment (MCI)

A condition of cognitive decline that is not consistent with normal aging

• Dementia

A constellation of symptoms including

Memory impairment One or more cognitive and/or linguistic impairments

• Primary progressive aphasia (PPA)

The progressive loss of linguistic abilities in contrast to relatively intact cognitive abilities

Hallowell, B. (2016). Aphasia and other acquired neurogenic language disorders: A guide for clinical excellence. San Diego, CA: Plural Publishing. ISBN13: 978-1-59756-477-9

Brooke Hallowell April 2017 11

What is dementia?

• The criteria for the diagnosis of dementia
• Memory impairment
• One or more cognitive/linguistic impairments
• Most common symptoms
• Memory problems
• Behavior problems
• People with dementia develop different

problems with

• Attention
• Executive functions
• Critical thinking
• Language

Source: “Alzheimer's disease brain”. by Garrondo, derivative work:, license CC.0. Public Domain [modified].

Hallowell, B. (2017). Aphasia and other acquired neurogenic language disorders: A guide for clinical excellence. San Diego, CA: Plural Publishing. ISBN13: 978-1-59756-477-9

What are common forms of dementia?

Dementia

Alzheimer's disease (AD) MCI due to AD Vascular dementia Dementia with Lewy bodies (DLB) Parkinson's disease dementia Frontotempo ral dementia (FTD) Huntington's disease Korsakoff's Syndrome Creutzfelt- Jacob disease AIDS dementia complex Hallowell, B. (2017). Aphasia and other acquired neurogenic language disorders: A guide for clinical excellence. San Diego, CA: Plural Publishing. ISBN13: 978-1-59756-477-9

Is there such a thing as “reversible” dementia?

• The term “reversible” dementia is inaccurate and misleading
• By definition, dementia is progressive and gets worse over time
• The “progressive” nature of dementia is the key to distinguish it from other

non-progressive, dementia-like disorders

• e.g., Pseudo-dementia (or transient confusional state)
• Situations in which dementia-like symptoms may be noted despite the

absence of a true dementia

• Depression
• Dietary imbalances
• Vitamin deficiencies
• Drug effects
• Drug interactions
• Post-surgical states

Hallowell, B. (2016). Aphasia and other acquired neurogenic language disorders: A guide for clinical excellence. San Diego, CA: Plural Publishing. ISBN13: 978-1-59756-477-9

What are implications of an incorrect diagnosis of dementia?

• Unnecessary difficult emotional reactions
• f patients and caregivers
• Hardships related to untoward stigma on

a social level

• Incorrect prescription of medication and
• ther interventions
• Being deemed ineligible for coverage of

some crucial rehabilitation-related services

• Some third-party payers consider dementia

to be a “red flag” diagnosis

Source: “Holzfigur” By Counselling, licensed under CC0 Public Domain.

Hallowell, B. (2017). Aphasia and other acquired neurogenic language disorders: A guide for clinical excellence. San Diego, CA: Plural Publishing. ISBN13: 978-1-59756-477-9

What is mild cognitive impairment (MCI)?

• A condition of cognitive decline that is not typical of normal aging
• Etiologies
• Neurodegenerative disease
• Head injury
• Neoplasm
• Infectious processes
• Metabolic disorders
• Memory problems are the most common complaints of people with MCI

Hallowell, B. (2017). Aphasia and other acquired neurogenic language disorders: A guide for clinical excellence. San Diego, CA: Plural Publishing. ISBN13: 978-1-59756-477-9

What are some special challenges in identifying etiologies of language disorders?

• Age
• Socioeconomic status
• Cultural/linguistic background
• Health status
• Emotional health
• Social support

Acquired vs. Exacerbated Individual Differences Concomitant Conditions Multiple Etiologies

Hallowell, B. (2017). Aphasia and other acquired neurogenic language disorders: A guide for clinical excellence. San Diego, CA: Plural Publishing. ISBN13: 978-1-59756-477-9

Brooke Hallowell April 2017 12

Cognitive-Linguistic Intervention for people with MCI and Dementia

Introduction

• Cognitive intervention may lead to changes in the brain:
• Increased brain metabolism
• Increased cortical thickness
• Increased density of white matter tracts
• Best outcomes achieved when implemented early (when individuals

with MCI retain the capability to learn and apply strategies) (Jean et al., 2010; Stoot & Spector, 2011)

What we do not know

• Are specific interventions best for specific deficits?
• What outcome measures are most valid?
• Delivery: Is individual treatment better than group treatment?
• Dosage: How long should treatment sessions last? How long should

intervention programs last?

• Long-term effects: How long will program effects last?

What we do know

• Use repetition-based intervention that targets specific cognitive

domains

• Provide direct training of strategies and functional skills
• Empower clients with education regarding healthy aging and brain

habits

• Provide goal-oriented, strategic social opportunities that support

cognitive engagement

When developing a Cognitive Intervention Program…

1. Base your program on a framework that considers the impact of cognitive impairment on lives of affected individuals

Health Condition: MCI Key Element addressed Body & Functions Brain damage leading to impairments in memory, language, EF Target-oriented repetition-based intervention Activity Ability to complete specific tasks Selection and direct training of memory strategies Participation Fulfillment of social roles Provision of goal-

• riented strategic social

engagement Contextual factors Address modifiable risk- and protective factors Empowerment through education about healthy aging

When developing a Cognitive Intervention Program…

• 2. Purpose should be to improve cognitive and social functions
• 3. Include outcome measures that assess effects on function, activity

limitation, life participation restrictions and personal and environmental factors

Brooke Hallowell April 2017 13

Outcome measures

• Include a mix of objective and subjective outcome measures
• Objective measures: standardized tests evaluating cognitive domains
• Subjective measures: questionnaires of client/ family perception, mood, and

participation)

• Include pre-and post assessments

Typical Formats

Duration:

• 8-24 sessions (plus booster sessions in regular intervals after completion of

the training)

• 60-120 minutes

Components:

• Individual and group sessions
• Computer-based and paper-and-pencil tasks arranged in a “circuit”

Key Elements

• 1. Repetition
• Practice increases cognitive reserve
• More practice leads to more resilience against decline
• Target specific cognitive domains based on clients’ impairment profile to

strengthen preserved functions

Key Elements : Repetition (continued)

Computer-based intervention

• Cost effective
• Provides multiple training options
• Standardized intervention procedures
• Easily accessed
• Immediate, objective review of performance
• Gradual increase in difficulty (if it can be tailored)
• Most clients are familiar with computer, smart phone, tablets and have access to the

internet regularly

Computer-based intervention

• Most robust improvements on trained cognitive task (limited support for

generalization)

• BUT: participants often feel as they have improved cognition due to

training

• Self-reported cognitive improvements, positive feelings about ones cognition

may have important implications for everyday cognitive functions

Key Elements : Repetition (continued)

Key Elements : Repetition (continued) Computer-based intervention

Barnes & Colleagues (2009)

• Efficacy and feasibility of computer-based home training to improve speed and accuracy

in auditory processing in people with MCI Methods

• Tx group: Posit Science software 100 min/day x 5 days/week x 8 wks
• Control group: reading the paper online, listening to audiobooks, play computer games…
• Outcome measures: RBANS (Repeatable Battery for the Assessment of

Neuropsychological Status) Results

• No sig. differences on the RBANS between groups and pre-and post-test comparison
• But: overall trend for improvement in treatment and control group
• Importance of personally relevant treatment materials – individualized treatment

matters

Brooke Hallowell April 2017 14

Key Elements : Repetition (continued) Computer-based intervention

• SLP role:
• Formulate goals
• Select best activity
• Evaluate progress
• Make program modification

Key Elements : Repetition (continued) Computer-based intervention

• Questions to consider when selecting a program:
• Does the client have access to computer?
• What programs require internet access?
• Cost?
• What specific cognitive skills are addressed in the program?
• Support for program effectiveness?
• Can program be tailored to individual needs?
• Does program measure progress?
• Does program adjust the level of difficulty?

Key Element 2: Provide direct training of strategies

• Memory strategy training positively affects other domains of

cognition

• Frequent issue: prospective memory training (often addressed

through external memory aids)

• Clare et al. (2009; 2011)
• 8 wk x 1-hr/week introduced to a series of mnemonic strategies
• Participants were allowed to select one or two strategies for functional goals

relating to leisure tasks, household activities..) to implement in daily life

Memory Strategies

• External memory aids (teach use of calendars, smart phones…)
• Adapting the environment
• Method of loci (mentally linking a place with each item to be remembered)
• Mind mapping (links around a central word or idea are made using a

diagram)

• Visual imagery (mental images are created to facilitate the learning and

recall of materials)

• Categorizations and hierarchical organization (aimed at classifying

information to be learned by semantic category or by order of importance)

• PQRST (a way of helping yourself to remember something you are reading,

such as a newspaper article)

• Chunking (grouping information to be remembered)

Memory Strategies

Memory aids

• Smartphones and diary or calendar applications
• Diaries
• Notebooks
• Lists
• Alarm clocks
• Calendars
• Wall charts
• Tape recorders and Dictaphones
• Electronic organizers
• Pagers
• Pill reminder boxes for medication
• Sticky notes
• Photo albums
• Cameras

Memory Strategies

Adapting the environment

• Keeping a notepad by the phone to make a note of phone calls

and messages

• Putting essential information on a noticeboard
• Deciding on a special place to keep important objects like keys,

wallets

• and always putting them back in the same place
• Attaching important items to your person so they can’t be

mislaid, for example using a neck cord for reading glasses

• Labeling cupboards and storage vessels as a reminder of where

things are kept

• Labeling perishable food with the date it was opened

Brooke Hallowell April 2017 15

Memory Strategies

• Method of loci (mentally linking a place with each item to be

remembered) https://www.youtube.com/watch?v=PIg73ppoVZw

Mind maps:

• main idea crystallized

in a central image

• main themes branch
• ff from the central

image

• Use images, words or

both

• The branches form a

connected nodal structure

• Provide a structure

for your thoughts and visual representation

Memory Strategies PQRST

a way of helping yourself to remember something you are reading, such as a newspaper article. PQRST stands for:

• Preview – scan the information to get a general idea of the

content

• Question – identify some questions you want to be able to

answer after you have read it and write them down

• Read – read the material closely
• State – repeat the main points to yourself by stating them in

summary form

• Test – test your knowledge by seeing if you can answer the

questions you wrote down earlier

Key Element 3: Empowerment through Education

• Educate about life style factors that enhance development of

cognitive reserve

• Small discussion groups provide opportunity for social engagement
• Topics:
• Health benefits of physical activity and how to integrate it into one’s life
• Benefit of sleep
• Value of addressing changes in hearing acuity and communication strategies
• Principles of cognitive reserve
• Self- identify activities participants find enjoyable and relaxing, such as

listening to music or exercising, and develop goals and a plan to indulge in them.

Key Element 4: Provide goal oriented social

• pportunities that support cognitive engagement
• Decreased level of social engagement in people with

MCI

• High-quality social relationships contribute to good

health

• Reason for the group format
• Participants often comment on feeling reassured

about knowing other individuals with similar problems

What are memory books and memory wallets and how are they implemented?

• Collections of pictures, phrases, and

words associated with familiar people, places, and events that a person may have difficulty remembering (Bourgeois, 1992)

• Memory books

Often in the form of three-ring binders Contain photographs and printed words Can easily be edited and added to over time Photo albums may also be used

• Memory wallets

Typically plastic wallet inserts Contain emergency contact information, words that are important to remember, scheduling/calendar/appointment information, addresses, names, phone numbers, and associated pictures

• They are generally used with people

who have memory loss.

• People with language of generalized

intellectual impairment

• People with memory loss associated with

TBI

Hallowell, B. (2016). Aphasia and other acquired neurogenic language disorders: A guide for clinical excellence. San Diego, CA: Plural Publishing. ISBN13: 978-1-59756-477-9

Brooke Hallowell April 2017 16

What are memory books and memory wallets and how are they implemented?

Hallowell, B. (2016). Aphasia and other acquired neurogenic language disorders: A guide for clinical excellence. San Diego, CA: Plural Publishing. ISBN13: 978-1-59756-477-9

• The rationale for the use of

memory wallets and memory books

• People with dementia tend to retain

long-term memory abilities far beyond the time that they lose short-term memory abilities

• Repeated practice with personally

relevant stimuli helps to enhance access to associated facts, words, and names

Consider these prompts for conversation:

• Was your son here this morning?
• I see you had a corgi named Willie. He was so cute. I used to

have a corgi, too. What did you like best about having a dog?

Caring Memories Book

Hallowell, B. (2016). Aphasia and other acquired neurogenic language disorders: A guide for clinical excellence. San Diego, CA: Plural Publishing. ISBN13: 978-1-59756-477-9

• https://www.youtube.com/watch?v=5JjCwoJLoXM

Reminiscence

• Reminiscence allows an individual to recall and reflect on

personal life stories and experiences.

• Reminiscence activities target long-term memories that tend to

remain intact despite more advanced memory loss, particularly

• nes that have significant emotional meaning for individuals,

allowing an individual who may have severe short-term memory impairments to demonstrate a completely different level of competence

Steps to Create Memory Books/wallets

• 1. Compose a book or wallet containing pages of words, personal

photographs, and/or personally relevant sentences.

• 2. Use declarative sentences to represent the facts in the book.
• 3. Select facts to include based on memory failures that often occur.

BIOGRAPHICAL INFORMATION: NAME

Make sure to select a picture that the individual is able to identify. For some, this may be a picture from their youth. For others, it may be a more current picture.

M

My name is Dorothy.

BIOGRAPHICAL INFORMATION: AGE & BIRTHDAY

Make sure that if you include the individual’s current age, there will be someone there to update it as the individual ages.

My birthday is July 8, 1931.

Brooke Hallowell April 2017 17

BIOGRAPHICAL INFORMATION: PLACE OF BIRTH

Include information that is important to the individual. Make sure the individual identifies with the images

• chosen. This could be a

picture of the individual’s house, or an area of the town that has meaning.

I was born and raised in Athens, Ohio.

FAMILY INFORMATION

Again, make sure the individual is able to relate to the person in the

• picture. Choose pictures

with the help of the individual, family members, and friends.

This is my husband, Larry.

FAMILY INFORMATION

It is also appropriate to include individualized descriptions of pictures, if the individual has the cognitive and linguistic skills to benefit from

• them. Talk to the

individual and their family about personal thoughts and memories attached to pictures.

Larry and I got married on September 22, 1949. It was a beautiful day.

FAMILY INFORMATION

If multiple people are in a picture, it is often helpful to name the individuals in the order they appear in the photograph. If the individual has difficulty naming the people in the picture, repeated verbal cues combined with pointing may help.

Larry and I had three children: Julie, Rich, and Catherine.

FAMILY INFORMATION

It is often helpful to include pictures from the individual’s past (such as the previous picture) to aid in reminiscence and conversation. It is also important to include more current picture, which might aid in recognition of family members currently.

This is my daughter Julie, with her husband Chad.

MY SCHEDULE

Include activities the individual has trouble remembering, or those that are associated with behaviors.

• For example, if the

individual exhibits anxiety

• ver eating meals, including

them on the schedule may be a reminder about when and where these happen.

• Use words and/or pictures,

as appropriate. Also, include activities that are personally important for the individual (i.e., watching TV with friends) My Schedule 5:00 am – Wake Up 6:30 am - Shower 7:30 am – Eat Breakfast 10:00 am – Watch TV with friends Etc.

Brooke Hallowell April 2017 18

MY SCHEDULE

Some individuals may benefit from a page-by- page schedule. Be sure to continuously consider the individuals cognitive and linguistic abilities while setting up the memory book.

I wake up at 5:00 am.

TARGET AREAS

This type of page can be included if an individual is constantly asking questions regarding his or her medication. Including this page in the Memory Book may reduce that problem behavior.

This is the nurse’s station. I go here to ask about my daily medication.

HOW TO USE: POSSIBLE GOALS

Increase the duration of engagement in conversation Produce more utterances within a conversation Produce fewer perseverative utterances Produce fewer off-topic utterances and more on-topic utterances Engage in a single topic for a greater number of conversational turns Produce utterances of greater length and complexity Produce less ambiguous (more easily interpretable) utterances Provide more appropriate answers to questions about related content Improve naming and accuracy of naming of people and object depicted

and labeled

Demonstrate independent use of the aid

HOW TO USE: POSSIBLE ACTIVITIES

Looking at and reading one page at a time, stopping to converse

about the relevant context

Looking at a picture and using open-ended prompts, such as “tell

me about…,” or “what was it like when you...”

Elaborating on comments made by the person Asking for additional details Reading words phrases aloud or asking the person to do so Having the person show to the book to someone else and explain

content within it

Suggesting looking at or discussing content on the book to distract

the individual when he or she is sad or engages in undesirable behavior.

HOW TO USE: WHOM ELSE TO INVOLVE

Training staff and family members to use the book in supported

communication, with encouragement for positive aspects, enhances the likelihood of meaningful conversations in future interactions.

ACTIVITY

Identify positive and negative aspects of example memory books

according to:

Design (use of pictures, layout, portability of the book, etc.) Content (type of sentences, ability to link sentences to pictures, etc.) Specific ways to use example memory books as: Memory aids AAC materials Direct treatment materials (consider possible goals from previous slide) General supports to assist in meaningful conversation

Brooke Hallowell April 2017 19

What is spaced retrieval training (SRT) and how is it implemented?

• A method of learning and retaining

information by recalling the information over increasingly longer periods of time (Camp, Foss,

O’Hanlon, & Stevens, 1996, p. 196)

• The goal of SRT (Bayles & Tomoeda, 1997; Camp et al., 1996;

Cherry & Simmons-D’Gerolamo, 2005)

• To enhance accessibility to stored

representations By repeatedly activating them By making a person aware of them

• It targets implicit memory
• Unconscious and involuntary memory

Considered to be relatively robust in people with memory disorders associated with TBI and various forms of dementia

• Classified as an errorless learning method
• There are two basic forms of SRT (Morrow &

Fridriksson, 2006)

• Fixed-interval/uniform approach

The time between trials remains constant Helps transfer information into long-term storage

• Randomized-interval/adjusted approach

The time between trials is adjusted according to the individual’s performance Enhances long-term retention Featured in most of the relevant published literature

Hallowell, B. (2016). Aphasia and other acquired neurogenic language disorders: A guide for clinical excellence. San Diego, CA: Plural Publishing. ISBN13: 978-1-59756-477-9

The goal is to promote the best quality of interactions, and thus quality of life, with people who have dementia

• F Face to face
• Face the individual directly
• Attract the individual's attention
• Maintain eye contact
• O Orientation
• Orient the individual by repeating key words several times
• Repeat sentences exactly
• Give the individual time to comprehend what you say
• C Continuity
• Continue the same topic of conversation for as long as possible
• Prepare the individual if a new topic must be introduced
• U Unsticking
• Help the individual become "unstuck" when he or she uses a

word incorrectly by suggesting the word they are looking for

• Repeat the individual's sentence using the correct word
• Ask, "Do you mean…?"
• S Structure
• Structure the questions to give the individual a simple

choice to respond with

• Provide only two options at a time
• Provide options that the individual would like
• E Exchange
• Keep up the normal exchange of ideas we find in

conversation

• Begin conversations with pleasant, normal topics
• Ask easy questions that the individual can answer
• Give the individual clues as to how to answer
• D Direct
• Keep sentences short, simple, and direct
• Use specific, concrete nouns, rather than pronouns
• Use hand signals, pictures, and facial expressions

What is the FOCUSED program and how is it implemented?

FOCUSED is an acronym representing each of the following communication strategies (Ripich, Wykle, & Niles, 1995)

Hallowell, B. (2016). Aphasia and other acquired neurogenic language disorders: A guide for clinical excellence. San Diego, CA: Plural Publishing. ISBN13: 978-1-59756-477-9

What are Montessori approaches to dementia management?

• Initially developed for use with children in educational environments
• Theoretical foundations of the Montessori approach
• Enhances activation of intact intellectual and communicative activities
• Improves compensatory strategies through any means of supported

communication

• Multimodal sensory exploration is encouraged

Hallowell, B. (2016). Aphasia and other acquired neurogenic language disorders: A guide for clinical excellence. San Diego, CA: Plural Publishing. ISBN13: 978-1-59756-477-9

What are additional forms of programming to support people with dementia?

• The Breakfast Club (Boczko, 1994)
• An example of a social approach used in a

nursing home context

• The motivation for this approach

Long-term care residents with MCI and dementia

Are at risk for social isolation Have reduced opportunities for social interaction

• Adaptable to individuals and context
• The Savvy Caregiver Program (SCP)
• An example of a caregiver training

program

• A packaged program focused on

mediating caregiver stress through improved interactions with people who have dementia

Hallowell, B. (2016). Aphasia and other acquired neurogenic language disorders: A guide for clinical excellence. San Diego, CA: Plural Publishing. ISBN13: 978-1-59756-477-9