Dealing with Dementia: Clients, Clinicians, and Caregivers

Dealing with Dementia: Clients, Clinicians, and Caregivers

Presented by:Presented by:

Dr. Kim McCullough, P.H.D., CCC-Dr. Kim McCullough, P.H.D., CCC-SLPSLP

Walt Greenslade, B.A., Graduate Walt Greenslade, B.A., Graduate ClinicianClinician

*Information and slides adapted from materials collected by Cindy Woodson and Suzanne Sprague

True or False:

1. Memory loss is a natural part of aging.

2. Alzheimer’s disease is not fatal.

3. Vitamin E is a possible treatment for slowing the progression of Alzheimer’s disease.

4. Drinking out of aluminum cans or cooking in aluminum pots and pans can lead to Alzheimer’s disease.

5. Aspartame (Nutrasweet) causes memory loss.

True or False (Cont.):

6. Flu shots increase risk of Alzheimer’s disease.

7. There are therapies available to stop the progression of Alzheimer's disease.

8. Approximately 5% of the population is likely to inherit Alzheimer’s disease from their family.

9. For the majority (95%) of cases of Alzheimer’s disease, there is no known cause.

10. Alzheimer’s disease was first discovered in 1906 by Dr. Alois Alzheimer.

Alzheimer’s Incidence

Dementia Defined:Dementia Defined:DSM-IV (1994) Diagnostic Criteria for DSM-IV (1994) Diagnostic Criteria for DementiaDementia

A. Impairment in short-term memory and long-A. Impairment in short-term memory and long-term memoryterm memory

B. At least 1 of the following:B. At least 1 of the following:1. Impairment in abstract thinking1. Impairment in abstract thinking2. Impaired judgment2. Impaired judgment3. Other disturbances of higher cortical 3. Other disturbances of higher cortical

functionfunction4. Personality change4. Personality change

C. Memory impairment and intellectual C. Memory impairment and intellectual impairment causing significant social and impairment causing significant social and occupational impairments.occupational impairments.

D. Absence of occurrence exclusively during D. Absence of occurrence exclusively during the course of Deliriumthe course of Delirium

E. Either of the following:E. Either of the following:

1. Evidence of an organic factor causing this 1. Evidence of an organic factor causing this impaired impaired memory and intellect.memory and intellect.

2. Impaired memory and intellect cannot be 2. Impaired memory and intellect cannot be accounted for by any non-organic mental accounted for by any non-organic mental

disorder.disorder.

Definition Continued

Dementia vs. Delirium

Delirium• Usually a transient condition

•Rapid Onset (a few hours to a few days)

•Characterized by confusion, disordered thinking, disorientation, agitation, hyperactivity, distractibility, and sometimes delusions and hallucinations

A senile plaque as seen by an electron microscope

Types of dementia – reversible and irreversible

Irreversible:

•Alzheimer’s•Pick’s Disease•Lewy Body Disease•Vascular dementia•Huntington’s Chorea

Reversible:

•Brain Tumor•Depression•Hypothyroidism•Drug Interactions•Nutrition Deficits

Huntington’s Chorea Video Clip

Diagnosis and Assessment of Dementia


How is Dementia Diagnosed?

•Patient History

•Physical Examination

•Neurological Evaluations

•Cognitive and Neuropsychological Tests

•Brain Scans

•Rating Scales


Tests and Rating Scales (to name a few):

•Mini Mental State Exam (MMSE)

•Arizona Battery for Communication Disorders of Dementia (ABCD)

•Functional Assessment of Communication Skills (ASHA FACS)

Pet Scan Images

Tools for Diagnosing Dementia

Pharmacological Treatment of Dementia

Cognex, Aricept, Exelon, Razadyne, & Namenda Q: What do they do?

A: With the exception of Namenda, they all block an enzyme in the brain that helps to remove Acetylcholine - a chemical messenger in the brain. People with AD typically have low levels of this helpful chemical messenger, so keeping this at higher levels helps to slow the progression of AD.

Q: What are the side effects?

A: Generally, cholinesterase inhibitors are well tolerated. Symptoms such as nausea, vomiting, loss of appetite, diarrhea, sleeplessness, and abnormal dreams are the most commonly reported side effects.


Q: What about Namenda?

A: Namenda essentially works to keep the neurons in the brain firing smoothly. It targets specific types of neurons and keeps them from over firing. When these neurons fire too often, the chemical result is an increase in free radicals that contribute to damage of surrounding brain tissue.

Q: What are the side effects?

The most commonly reported side effects are: constipation, dizziness, headache, and general pain.

Q: Are there any new drugs coming out soon?

A: It’s difficult to say what will actually make it to the market, but there are several promising new treatments on the later stages of clinical trials. One such drug attacks the formation of the plaques that form as a result of AD. However, there is still no miracle cure for AD coming out in the foreseeable future.

*Vaccines!?!?!? WHERE DO I SIGN UP??


Therapy + DrugsTherapy + Drugs

A study done by Requena et al. looked at 86 A study done by Requena et al. looked at 86 individuals with dementia over the course of a individuals with dementia over the course of a year (2004). year (2004).

Cahn-Weiner et al. found no statistically Cahn-Weiner et al. found no statistically significant differences between a group receiving significant differences between a group receiving both ChEIs and cognitive stimulation and a both ChEIs and cognitive stimulation and a control group (2003). control group (2003).

Another study of interest that specifically looks at Another study of interest that specifically looks at the combined effects of ChEIs and cognitive the combined effects of ChEIs and cognitive intervention was done by Chapman et al. in 2004. intervention was done by Chapman et al. in 2004.

•Identification/assessment

•Intervention

•Inter-professional collaboration

•Case management

•Education/advocacy

The Role of the SLP for Persons with

Cognitive-Communication Impairments

Treatment Goals A Model for Treatment (adapted from Tomoeda, 2001 Arksha)

1. Improve orientation, attention, and association

2. Reduce demands on episodic and working memory systems

3. Increase reliance on spared recognition and procedural/habit memory systems

4. Provide sensory stimulation to evoke positive fact memory, action, and emotion

Treatment Options for SLPs

•Spaced Retrieval Training (SRT) – focuses on strengths and existing memory function

•Small Group Therapy- includes compensatory strategies for enabling communication – no interruptions when they’re talking, etc. (Includes Reminiscence therapy and Breakfast Club)

•Memory notebooks – compensatory strategy for coping with memory loss.

•Validation Therapy

Available Evidence: Available Evidence: DementiaDementia

Interventions Identified:Interventions Identified: 1. Validation Therapy1. Validation Therapy 2. Reality Orientation Therapy2. Reality Orientation Therapy 3. Reminiscence Therapy3. Reminiscence Therapy 4. Sensory Stimulation4. Sensory Stimulation 5. Spaced Retrieval Training5. Spaced Retrieval Training

Dementia: Validation Dementia: Validation TherapyTherapy

Results?Results? Qualitative descriptions of improved Qualitative descriptions of improved

mood, communicative interactions from mood, communicative interactions from staff, family members staff, family members (Brack(Brack, 1997; Touzinsky, 1998), 1997; Touzinsky, 1998)

Changes in behavior:Changes in behavior: Reduced physically & verbally aggressive Reduced physically & verbally aggressive

behavior behavior (Toseland, 1997)(Toseland, 1997) Increased smiling, eye contact, touching, Increased smiling, eye contact, touching,

talking, showing leadership and physical talking, showing leadership and physical participation during VT sessions participation during VT sessions (Brack, 1997)(Brack, 1997)

Increased initiation & verbal interaction Increased initiation & verbal interaction after VT for 2/3 participants after VT for 2/3 participants (Morton & Bleathman, (Morton & Bleathman, 1991)1991)

Dementia: Validation Dementia: Validation TherapyTherapy

Clinical Application:Clinical Application:

Anecdotal evidence that VT has a Anecdotal evidence that VT has a generally positive effect on facilitating generally positive effect on facilitating communication, increasing verbal communication, increasing verbal interactions and decreasing some interactions and decreasing some problem behaviors.problem behaviors.

Rationale/principles of VT could be Rationale/principles of VT could be taught to family members & caregivers taught to family members & caregivers to increase meaningful communication in to increase meaningful communication in individuals with AD.individuals with AD.

Dementia: Reality Orientation Dementia: Reality Orientation TherapyTherapy

Results?Results? Reduced depression and anxiety Reduced depression and anxiety (Spector et (Spector et

al., 2001)al., 2001)

Gains in orientation and language Gains in orientation and language over control group, but same gains over control group, but same gains demonstrated by ‘socialdemonstrated by ‘social interaction’ interaction’ group group (Gerber et al., 1991)(Gerber et al., 1991)

4/6 studies reported significant 4/6 studies reported significant differences in MMSE scores between differences in MMSE scores between control & treatment groups after ROTcontrol & treatment groups after ROT

Dementia: Reality Orientation Dementia: Reality Orientation TherapyTherapy

Clinical Application:Clinical Application: In general, formal ROT can have In general, formal ROT can have

positive effects on cognitive positive effects on cognitive functioning of individuals with very functioning of individuals with very mild or mild-moderate ADmild or mild-moderate AD

Positive relationship between Positive relationship between duration of treatment and cognitive duration of treatment and cognitive outcomesoutcomes

Dementia: Dementia: Reminiscence Reminiscence TherapyTherapy

Results?Results? Generally positive results of group RT Generally positive results of group RT

across all studies, on cognition, affect, across all studies, on cognition, affect, behavior and functioning of moderate-behavior and functioning of moderate-severe patientssevere patients

Group RT had a greater effect on patients Group RT had a greater effect on patients in hospital setting vs. community day-care in hospital setting vs. community day-care setting setting (Head et al., 1990)(Head et al., 1990)

Individuals who attended day care Individuals who attended day care (regardless if they received RT or not) (regardless if they received RT or not) improved on cognitive measures vs. improved on cognitive measures vs. control group who did not attend day care control group who did not attend day care (Nomura, 2002)(Nomura, 2002)

Dementia: Dementia: Reminiscence Reminiscence TherapyTherapy

Clinical Application: Clinical Application: Fair amount of certainty that group Fair amount of certainty that group

RT has positive effects on mood, RT has positive effects on mood, communication and cognition of communication and cognition of individuals with dementiaindividuals with dementia

Difficult to tease apart what aspect Difficult to tease apart what aspect of RT is contributing most to of RT is contributing most to improvements: sensory stimulation, improvements: sensory stimulation, social interaction, positive social interaction, positive interactions with trained facilitators, interactions with trained facilitators, etc.etc.

Dementia: Dementia: Sensory Sensory Stimulation: Memory Stimulation: Memory Wallets & NotebooksWallets & Notebooks

Results?Results? Generally positive effects observed on Generally positive effects observed on

meaningfulness of utterances during meaningfulness of utterances during conversations between individuals with AD conversations between individuals with AD and caregivers, nurses’ assistants, other and caregivers, nurses’ assistants, other dementia patientsdementia patients

More on-topic, factual statements produced; More on-topic, factual statements produced; fewer ambiguous, nonsensical utterancesfewer ambiguous, nonsensical utterances

Variability in performance as a function of Variability in performance as a function of severity levelseverity level

Some subjects still showed wallet use at Some subjects still showed wallet use at follow-up testing up to 30 months later follow-up testing up to 30 months later (Bourgeois, 1990; Bourgeois, 1992)(Bourgeois, 1990; Bourgeois, 1992)

Dementia: Dementia: Sensory Stimulation: Sensory Stimulation: Memory Wallets & NotebooksMemory Wallets & Notebooks

Clinical Application Clinical Application Use of memory wallets/notebooks Use of memory wallets/notebooks

contributed to improved ‘conversations’ contributed to improved ‘conversations’ between AD patients and others, between AD patients and others,

BUT ‘conversation’ consisted of patient BUT ‘conversation’ consisted of patient being asked a question, and having being asked a question, and having him/her read the statement in the notebookhim/her read the statement in the notebook

Need a sense of how individuals with AD Need a sense of how individuals with AD would perform without printed material in would perform without printed material in front of them to refer to for answersfront of them to refer to for answers

Dementia: Spaced Retrieval Dementia: Spaced Retrieval TrainingTraining

What are the results?What are the results? Large majority of the participants Large majority of the participants

learned some or all of the target learned some or all of the target information and/or behaviorsinformation and/or behaviors

Maintenance of learned information Maintenance of learned information or behaviors reported in 12 studiesor behaviors reported in 12 studies

Generalization reported in six studiesGeneralization reported in six studies Object-name associationsObject-name associations Face-name associations Face-name associations Cue-behavior associationsCue-behavior associations

Dementia: Spaced Retrieval Dementia: Spaced Retrieval TrainingTraining

Clinical Application: Clinical Application: Individuals with mild to severe dementia who Individuals with mild to severe dementia who

have the ability to engage in structured training have the ability to engage in structured training tasks have been shown to benefit from SRT tasks have been shown to benefit from SRT

SRT sessions conducted weekly or more SRT sessions conducted weekly or more frequentlyfrequently

Improvement in the acquisition, retention and Improvement in the acquisition, retention and generalization of trained information and/or generalization of trained information and/or skillsskills

No change in global cognitive functioning or No change in global cognitive functioning or general memory function as a result of traininggeneral memory function as a result of training

Caregiver Information

• Caregivers spend 40 to 100 hours weekly with each person suffering from AD

• Challenges include:•Social isolation•Feelings of guilt•High emotions•Coping skills•Lack of knowledge about AD and its treatments

•Approximately 90% of caregivers report that they are affected emotinally, frustrated, and/or drained

*(Adapted from Schluterman, K., Alzheimer’s Disease Overview)



Ten Communication Strategies frequently mentioned in the AD literature.

1. Eliminate distractions2. Approach slowly, eye contact3. Simple sentences4. Slow speech rate5. One question/instruction6. Yes/no question7. Repeat message with the same wording8. Paraphrase repeated messages9. Avoid interrupting the person10. Encourage the person to describe the word he is searching for11.12.13.

Fewer communication breakdowns occurred with these strategies:

More communication breakdowns occurred with these strategies:

No clear difference in communication breakdown occurred with these strategies:


*Give us time to speak, try not to finish our sentences, and don’t let us feel embarrassed if we loose the thread of what we say

*Don’t rush into something, give us time to respond and let you know whether we really want to do it

*Don’t ask questions that will alarm us or make us feel uncomfortable

*If we have forgotten something special, don’t assume it wasn’t special for us too, just give us a gentle prompt

Communication Tips from Christine Bryden, diagnosed with dementia at

age 46

Communication Tips from Christine Bryden, diagnosed with dementia at

age 46

*But don’t try too hard to help us remember something that just happened. If it didn’t register we are never going to be able to recall it

*Avoid background noise if you can

*If children are underfoot remember we will get tired very easily and find it hard to concentrate

*Maybe earplugs for a visit to shopping centers or other noisy places

Environmental Factors: Positive and Negative

Visual

Auditory

Tactile/Olfactory

Space

ReferencesReferencesAmerican Speech-Language-Hearing Association. (2005). American Speech-Language-Hearing Association. (2005). The roles of speech-language The roles of speech-language

pathologists working with individuals with dementia: Technical reportpathologists working with individuals with dementia: Technical report. Rockville, . Rockville, MD: Author.MD: Author.

Bottino, M. C., Carvalho, A. M., Alvarez, A. M., Avila, R., Zukauskas, P. R., Bustamante, Bottino, M. C., Carvalho, A. M., Alvarez, A. M., Avila, R., Zukauskas, P. R., Bustamante, E. Z., Adrade, F. C., Hototian, S. R., Saffi, F., & Camargo, H. P. (2005). Cognitive E. Z., Adrade, F. C., Hototian, S. R., Saffi, F., & Camargo, H. P. (2005). Cognitive rehabilitation combined with drug treatment in Alzheimer’s disease patients: A pilot rehabilitation combined with drug treatment in Alzheimer’s disease patients: A pilot study. study. Clinical Rehabilitation, 19Clinical Rehabilitation, 19, 861-869., 861-869.

Bourgeois, M. S., (1991). Communication Treatment for Adults with Dementia. Journal Bourgeois, M. S., (1991). Communication Treatment for Adults with Dementia. Journal of Speech and Hearing Research, 34, 831-844.of Speech and Hearing Research, 34, 831-844.

Bourgeois, M. S., (1992). Evaluating Memory Wallets in Conversations With Persons Bourgeois, M. S., (1992). Evaluating Memory Wallets in Conversations With Persons With Dementia. With Dementia. Journal of Speech and Hearing Research, 35Journal of Speech and Hearing Research, 35, 1344-1357., 1344-1357.

Bourgeois, M. S., Camp, C., Rose, M., White, B., Malone, M., Carr, J., Rovine, M. (2003). Bourgeois, M. S., Camp, C., Rose, M., White, B., Malone, M., Carr, J., Rovine, M. (2003). A comparison of training strategies to enhance the use of external aids by persons A comparison of training strategies to enhance the use of external aids by persons with dementia. with dementia. Journal of Communication Disorders, 36Journal of Communication Disorders, 36, 361-378., 361-378.

Camp, C. J., & Stevens, A. B. (1990). Spaced-retrieval: A memory intervention for Camp, C. J., & Stevens, A. B. (1990). Spaced-retrieval: A memory intervention for dementia of the Alzheimer’s type. dementia of the Alzheimer’s type. Clinical Gerontologist, 10Clinical Gerontologist, 10(11), 58-61.(11), 58-61.

Camp, C. J., Foss, J. W., O’Hanlon, A. M., & Stevens, A. B. (1996). Memory interventions Camp, C. J., Foss, J. W., O’Hanlon, A. M., & Stevens, A. B. (1996). Memory interventions for persons with dementia. for persons with dementia. Applied Cognitive Psychology, 10Applied Cognitive Psychology, 10, 193-210., 193-210.

Cahn-Weiner, D. A., Malloy, P. F., Rebok, G. W., & Ott, B. R. (2003). Results of a Cahn-Weiner, D. A., Malloy, P. F., Rebok, G. W., & Ott, B. R. (2003). Results of a randomized placebo-controlled study of memory training for mildly impaired randomized placebo-controlled study of memory training for mildly impaired Alzheimer’s disease patients. Alzheimer’s disease patients. Applied Neuropsychology, 10Applied Neuropsychology, 10, 215-223., 215-223.

ReferencesReferencesChapman, S. B., Weiner, M. F., Rackley, A., Hynan, L. S., & Zeintz, J. (2004). Chapman, S. B., Weiner, M. F., Rackley, A., Hynan, L. S., & Zeintz, J. (2004).

Effects of cognitive-communication stimulation for Alzheimer’s disease Effects of cognitive-communication stimulation for Alzheimer’s disease patients treated with donepezil. patients treated with donepezil. Journal of Speech, Language, and Journal of Speech, Language, and Hearing Research, 47Hearing Research, 47, 1149-1163., 1149-1163.

Kimball, J. W. (2004, December 9). Kimball, J. W. (2004, December 9). EnzymesEnzymes. Retrieved November 16, 2006, . Retrieved November 16, 2006, from from http://users.rcn.com/jkimball.ma.ultranet/BiologyPages/E/Enzymes.htmlhttp://users.rcn.com/jkimball.ma.ultranet/BiologyPages/E/Enzymes.html

Reese, P. B. (2000). The Source for Alzheimer’s & Dementia. Reese, P. B. (2000). The Source for Alzheimer’s & Dementia. LinguiSystemsLinguiSystems, , East Moline, IL.East Moline, IL.

Small, J.A., Gutman, G., Makela, S. & Hillhouse, B. (2003). Effectiveness of Small, J.A., Gutman, G., Makela, S. & Hillhouse, B. (2003). Effectiveness of communication strategies used by caregivers of persons with alzhimer’s communication strategies used by caregivers of persons with alzhimer’s disease during activities of daily living. disease during activities of daily living. Journal of Speech, Language, and Journal of Speech, Language, and Hearing Research, 46,Hearing Research, 46, 353-367. 353-367.

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Dealing with Dementia: Clients, Clinicians, and Caregivers