1. Dealing with Dementia:
Clients, Clinicians, and Caregivers

2. Presented by: Dr. Kim McCullough, P.H.D., CCC-SLP
Walt Greenslade, B.A., Graduate Clinician
*Information and slides adapted from materials collected by Cindy Woodson and Suzanne Sprague

3. 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.

4. True or False (Cont.):
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.

5. Alzheimer’s Incidence

6. Dementia Defined: DSM-IV (1994) Diagnostic Criteria for Dementia A
Dementia Defined: DSM-IV (1994) Diagnostic Criteria for Dementia A. Impairment in short-term memory and long-term memory B. At least 1 of the following: 1. Impairment in abstract thinking 2. Impaired judgment 3. Other disturbances of higher cortical function 4. Personality change C. Memory impairment and intellectual impairment causing significant social and occupational impairments.

7. Definition Continued
D. Absence of occurrence exclusively during the course of Delirium E. Either of the following: 1. Evidence of an organic factor causing this impaired memory and intellect. 2. Impaired memory and intellect cannot be accounted for by any non-organic mental disorder.

8. 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

9. A senile plaque as seen by an electron microscope

10. Types of dementia – reversible and irreversible
Alzheimer’s
Pick’s Disease
Lewy Body Disease
Vascular dementia
Huntington’s Chorea
Reversible:
Brain Tumor
Depression
Hypothyroidism
Drug Interactions
Nutrition Deficits

11. Huntington’s Chorea Video Clip

12. Diagnosis and Assessment of Dementia

13. Diagnosis and Assessment of Dementia
How is Dementia Diagnosed?
Patient History
Physical Examination
Neurological Evaluations
Cognitive and Neuropsychological Tests
Brain Scans
Rating Scales
*Handouts for Rating Scales

14. 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)
*Handouts for Rating Scales
Note for the MDS: A result of the Omnibus Budget Reconciliation Act in This mandated the physical and psychological condition of long-term health care patients. SLPs contribute to this, but a nursing coordinator will be responsible for the MDS as a whole. It is important to us because it has to evaluate the ability to hear, comprehend and produce language.

15. Pet Scan Images
Positron Emission Tomography works by looking at how the brain absorbs glucose as a radioisotope. An active brain absorbs the glucose and the inactive brain doesn’t absorb it.

16. Tools for Diagnosing Dementia

19. “One molecule of acetylcholinesterase breaks down 25,000 molecules of acetylcholine each second. This speed makes possible the rapid "resetting" of the synapse for transmission of another nerve impulse” (Kimball, 2006 internet).

20. 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.

21. 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.

22. Pharmacological Treatment of Dementia
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??

23. Therapy + Drugs
A study done by Requena et al. looked at 86 individuals with dementia over the course of a year (2004).
Cahn-Weiner et al. found no statistically significant differences between a group receiving both ChEIs and cognitive stimulation and a control group (2003).
Another study of interest that specifically looks at the combined effects of ChEIs and cognitive intervention was done by Chapman et al. in 2004.

24. Cognitive-Communication Impairments
The Role of the SLP
for Persons with
Cognitive-Communication Impairments
Identification/assessment
Intervention
Inter-professional collaboration
Case management
Education/advocacy

25. 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

26. 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

27. Available Evidence: Dementia
Interventions Identified:
1. Validation Therapy
2. Reality Orientation Therapy
3. Reminiscence Therapy
4. Sensory Stimulation
5. Spaced Retrieval Training

28. Dementia: Validation Therapy
Results?
Qualitative descriptions of improved mood, communicative interactions from staff, family members (Brack, 1997; Touzinsky, 1998)
Changes in behavior:
Reduced physically & verbally aggressive behavior (Toseland, 1997)
Increased smiling, eye contact, touching, talking, showing leadership and physical participation during VT sessions (Brack, 1997)
Increased initiation & verbal interaction after VT for 2/3 participants (Morton & Bleathman, 1991)
Improved cognition as measured by HDS (Brack, 1997)
Validation therapy is designed to assist the moderately to severely disoriented demented person in learning that they can replace their confused thinking with cogent emotional memories. In this way, patients regain self-worth, reduce emotional stress, feel satisfied with their lives, and help resolve unfinished conflicts with the past
Can be used in the middle or advanced stages

29. Dementia: Validation Therapy
Clinical Application:
Anecdotal evidence that VT has a generally positive effect on facilitating communication, increasing verbal interactions and decreasing some problem behaviors.
Rationale/principles of VT could be taught to family members & caregivers to increase meaningful communication in individuals with AD.

30. Dementia: Reality Orientation Therapy
Results?
Reduced depression and anxiety (Spector et al., 2001)
Gains in orientation and language over control group, but same gains demonstrated by ‘social interaction’ group (Gerber et al., 1991)
4/6 studies reported significant differences in MMSE scores between control & treatment groups after ROT
ROT is a re-learning process that involves re-orienting the individuals to the physical environment, time, persons, and past events through environmental and interpersonal cues. This process informs persons about significant factors in their environment.
Used during the early stage

31. Dementia: Reality Orientation Therapy
Clinical Application:
In general, formal ROT can have positive effects on cognitive functioning of individuals with very mild or mild-moderate AD
Positive relationship between duration of treatment and cognitive outcomes
Important to use a cognitive measure other than the MMSE when assessing performance

32. Dementia: Reminiscence Therapy
Results?
Generally positive results of group RT across all studies, on cognition, affect, behavior and functioning of moderate-severe patients
Group RT had a greater effect on patients in hospital setting vs. community day-care setting (Head et al., 1990)
Individuals who attended day care (regardless if they received RT or not) improved on cognitive measures vs. control group who did not attend day care (Nomura, 2002)
Groups provide members with an opportunity to socialize and communicate where members are allowed to recall and share memories without being labeled as “living in the past”
Middle stages

33. Dementia: Reminiscence Therapy
Clinical Application:
Fair amount of certainty that group RT has positive effects on mood, communication and cognition of individuals with dementia
Difficult to tease apart what aspect of RT is contributing most to improvements: sensory stimulation, social interaction, positive interactions with trained facilitators, etc.

34. Dementia: Sensory Stimulation: Memory Wallets & Notebooks
Results?
Generally positive effects observed on meaningfulness of utterances during conversations between individuals with AD and caregivers, nurses’ assistants, other dementia patients
More on-topic, factual statements produced; fewer ambiguous, nonsensical utterances
Variability in performance as a function of severity level
Some subjects still showed wallet use at follow-up testing up to 30 months later (Bourgeois, 1990; Bourgeois, 1992)

35. Dementia: Sensory Stimulation: Memory Wallets & Notebooks
Clinical Application
Use of memory wallets/notebooks contributed to improved ‘conversations’ between AD patients and others,
BUT ‘conversation’ consisted of patient being asked a question, and having him/her read the statement in the notebook
Need a sense of how individuals with AD would perform without printed material in front of them to refer to for answers

36. Dementia: Spaced Retrieval Training
What are the results?
Large majority of the participants learned some or all of the target information and/or behaviors
Maintenance of learned information or behaviors reported in 12 studies
Generalization reported in six studies
Object-name associations
Face-name associations
Cue-behavior associations
An intervention strategy in which an individual practices successfully recalling information over progressively longer intervals of time.
I don’t know who you are but I know your name
Important names, use of daily planner, caregiver name, refer to care with answer of repetitive question

37. Dementia: Spaced Retrieval Training
Clinical Application:
Individuals with mild to severe dementia who have the ability to engage in structured training tasks have been shown to benefit from SRT
SRT sessions conducted weekly or more frequently
Improvement in the acquisition, retention and generalization of trained information and/or skills
No change in global cognitive functioning or general memory function as a result of training
Clients learn without necessarily remembering they have previously performed the task

38. 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)

39. Caregiver Information

40. Caregiver Information
Ten Communication Strategies frequently mentioned in the AD literature.
Eliminate distractions
Approach slowly, eye contact
Simple sentences
Slow speech rate
One question/instruction
Yes/no question
Repeat message with the same wording
Paraphrase repeated messages
Avoid interrupting the person
Encourage the person to describe the word he is searching for
11.
12.
13.

41. Caregiver Information
Fewer communication breakdowns occurred with these strategies:
More communication breakdowns occurred with these strategies:
No clear difference in communication breakdown occurred with these strategies:

42. Communication Tips from Christine Bryden, diagnosed with dementia at age 46
*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

43. 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

44. Environmental Factors: Positive and Negative
Visual
Auditory
Tactile/Olfactory
Space

45. References
American Speech-Language-Hearing Association. (2005). The roles of speech-language pathologists working with individuals with dementia: Technical report. Rockville, MD: Author.
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 rehabilitation combined with drug treatment in Alzheimer’s disease patients: A pilot study. Clinical Rehabilitation, 19,
Bourgeois, M. S., (1991). Communication Treatment for Adults with Dementia. Journal of Speech and Hearing Research, 34,
Bourgeois, M. S., (1992). Evaluating Memory Wallets in Conversations With Persons With Dementia. Journal of Speech and Hearing Research, 35,
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 with dementia. Journal of Communication Disorders, 36,
Camp, C. J., & Stevens, A. B. (1990). Spaced-retrieval: A memory intervention for dementia of the Alzheimer’s type. Clinical Gerontologist, 10(11),
Camp, C. J., Foss, J. W., O’Hanlon, A. M., & Stevens, A. B. (1996). Memory interventions for persons with dementia. Applied Cognitive Psychology, 10,
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 Alzheimer’s disease patients. Applied Neuropsychology, 10,

46. References
Chapman, S. B., Weiner, M. F., Rackley, A., Hynan, L. S., & Zeintz, J. (2004). Effects of cognitive-communication stimulation for Alzheimer’s disease patients treated with donepezil. Journal of Speech, Language, and Hearing Research, 47,
Kimball, J. W. (2004, December 9). Enzymes. Retrieved November 16, 2006, from
Reese, P. B. (2000). The Source for Alzheimer’s & Dementia. LinguiSystems, East Moline, IL.
Small, J.A., Gutman, G., Makela, S. & Hillhouse, B. (2003). Effectiveness of communication strategies used by caregivers of persons with alzhimer’s disease during activities of daily living. Journal of Speech, Language, and Hearing Research, 46,