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
Diagnosis and Assessment of Dementia
How is Dementia Diagnosed?
•Patient History
•Physical Examination
•Neurological Evaluations
•Cognitive and Neuropsychological Tests
•Brain Scans
•Rating Scales
Diagnosis and Assessment of Dementia
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.
Pharmacological Treatment of Dementia
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??
Pharmacological Treatment of Dementia
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)
Caregiver Information
Caregiver Information
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:
Caregiver Information
*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
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