10/22/19 - wmich.edu
TRANSCRIPT
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AgingtoDementiaContinuum:CriticalRolesforSpeech-Language
Pathologists&Audiologists
NidhiMahendra,Ph.D.,CCC-SLPAssociateProfessor,CommunicativeDisorders&Sciences
Director,SpartanAphasiaResearchClinic(SPARC)AssociateDirector,CenterforHealthyAginginMulticulturalPopulations
VanRiperLecture–October2019
Disclosures• Travelcostsandspeakerhonorarium-WMU
• PriororcurrentgrantfundingfromtheCSUChancellor’sOffice,TCWF,ASHA,ElCaminoHealthcareDistrict,andtheWestFoundation
• ASHA:CRISPCommitteeMember;CEcontentreviewer/presenter
• Non-financialrelationshipswithappsSpeakabooandSmartAp
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Deepgratitude
• Lifein3countriesandcultures• Lossandresilience–earlylifethemes• “Toughlove”mentoring• Clientsandstudents–thebestteachers
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Learningobjectives1. DefineMCIandDementia2. Identifyleadingcausesandcharacteristicsof4typesof
irreversibledementias3. Identifybiopsychosocial,lifeparticipation,andsocialjustice
approachesthatinformassessmentandinterventionswithOA4. Listevidence-basedexamplesofscreeningandassessment
measuresusefulontheaging-MCI-dementiaspectrum5. Describekeycategoriesofinterventiontechniquesforpersons
withMCIanddementia6. Discusstheimportanceofinterprofessionalpracticeinserving
personswithMCIanddementia
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MildCognitiveImpairmentMCI
What is MCI?
• A transition stage – a condition of intermediate symptomatology - between the cognitive decline of normal aging and the more serious impairments of AD. (Petersen, 2003; Mayo Clinic, 2009)
• A prodromal state for dementia.
• Per the American College of Physicians, MCI affects approximately 20% of the population past the age of 70 years.
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Relationship between healthy aging, MCI, and Alzheimer’s disease
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MCI and AD Trajectory
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© National Institutes on Aging, 2007 www.nia.nih.gov 9
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ClinicalCriteriaforMCIpertheAmericanAcademyofNeurology
• Memorycomplaint,corroboratedbyaninformant• Objectivememoryimpairmentforageandeducation
level• Generallyintactoverallcognitivefunction• Essentiallypreservedactivitiesofdailyliving• Notdemented
MayoClinicAlzheimerDiseaseCenterPetersenetal.1999,Petersenetal.,2001,Petersen&Negash(2008)
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TypesofMCI• AmnesticMCI-Singledomain
– Mostcommon– MajorityofclientswithamnesticMCIprogresstoAD
• AmnesticMCI–MultipleDomain• NonamnesticMCI-SingleDomainRelativelyisolatedimpairmentinasinglenon-memorydomainsuchasexecutivefunction,visuospatialprocessing,orlanguage.• NonamnesticMCI-Multipledomain
– Slightimpairmentinmultiplenon-memorydomains,notenoughtoconstitutedementia
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MCIandbrain-basedchanges
• MCIisassociatedwiththesametypesofbrainchangesseeninADorotherdementiatypes
• DifferenceisintheextentofthesechangesinthatthesechangesaremorelimitedinMCI
• Noteworthychangesare:– Betaamyloidplaques– Neurofibrillarytangles(oftauprotein)– Shrinkageofthehippocampus– EvidenceofundocumentedstrokesorTIAs– Lewybodies
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MCItypesandprogressiontodementia
• PersonswithamnesticMCIaremorelikelytoconverttoadementiathannon-amnesticMCItypes.
• Thegreaterthenumberofcognitivedeficitsandtheearliertheypresent,thegreaterthepossibilityofconversionofMCItodementia.
• WhenMCIconvertstodementia,itmostoftenconvertstoAD.
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Petersen & Negash (2008) © CNS Spectrums 14
ScreeningandassessmentforMCI
Measures that have been used traditionally: – Clinical Dementia Rating Scale*
CDR=0.5 suggests MCI – Global Deterioration Scale
GDS Stage 3 suggests MCI – Mini Mental State Exam (MMSE)
– Nonstandardized assessment Using subtests of memory or cognitive batteries
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Measurespreferredbyresearchers
• MMSEScoreswithage-andeducationcorrections(Crumetal.,
1993,JAMA)• DementiaRatingScale(DRS-2;Mattisetal.,1982)• MontrealCognitiveAssessment(MoCA)http://www.mocatest.org(Nasreddineetal,2005)
• RepeatableBatteryfortheAssessmentofNeuropsychologicalStatus(RBANS;Randolphetal.,1998)
• CLQT
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CaseFilesMeetMr.BH
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Age:80,YrsEd:18
• Initialreferral:Episodesofbeingverballyargumentative,gotslightlymoreagitatedthannecessaryinstraysituations
• Livingsituation/ADLs:Independentliving,noADLimpairment,noself-reportofmemoryproblems*,staffreportedincreasedforgetting
• MMSE:Score25/30;notnormalforhisageandyrsofeducation
• Readingcomprehensionscreen• Other:MildtomoderatehighfrequencyHL,U/Lhgaid,no
speechdiscriminationproblems,novisionproblems,notdepressed
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Mr.BH:MCI• DementiaRatingScale-2–firsttestingAttention:Noimpairment(belowaverage)Initiation/Perseveration:Mildimpairment
VisuospatialProcessing:Noimpairment(belowaverage)Conceptualization(semanticmemory):Noimpairment(belowaverage)Memory:19th–28thpercentile(mildimpairment)
• RivermeadBehavioralMemoryTest-2Episodicmemoryforvisualinformation–UnimpairedEpisodicmemoryforverbal/spatialinformation–MildlyImpairedProspectivememory:UnimpairedOrientation:Unimpaired 19
SummaryoffindingsforBH
• DRS-2andRBMT-2:Multiple-domainMCI
• Criteriametfordiagnosisofdementia(AD)3yearslater,
althoughprescribedAriceptoneyearfromthefirsttesting.
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Dementia
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Risk factors for
Dementia
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Dementiaisasyndromecharacterizedbyacquired,persistentimpairmentof
multiplecognitivedomains
GrabowskiandDamasio(2004)
Memory Attention ExecutiveFunction
Language&Commn.
Visuo-spatialAbility
SocialFunctioning
OccupationalFunctioning
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DSM-5andDementia
• Newcategory:NeurocognitiveDisorders
MildNCD(1-2SDrange;3rdto16thpercentile)• Moderatecognitivedecline• IADLsintact• Notduetodeliriumorothermentaldisorder• E.g.,MildCognitiveImpairment(MCI)
MajorNCD(Below2SDor3rdpercentile)• Significantcognitivedecline• IADLsaffected• Notduetodeliriumorothermentaldisorder• E.g.,Dementia(2ormorecognitivedomainsaffected),TBI
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LeadingCausesofIrreversibleDementia
• Alzheimer’sdisease(AD)• Vasculardisease(VaD)
• Frontotemporallobardegeneration(FTLD)
• MixedDementia
• DementiawithLewyBodies(DLB)• Corticobasaldegeneration(CBD)• AIDSDementiaComplex(ADC)• DementiaduetoParkinson’sDisease(DPD)
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QuotableQuote
“ThepointisAlzheimer’sisalongillnessandhastakensomuchfromus.Idon’twanttospend5or10or20yearswringingmyhandsandfeelingsorry.Mymottois“Alzheimer’swithattitude,”oronsomedays,“Damnthedementia.”
FRED,ahusband
VoicesofAlzheimer’s
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Alzheimer’sDisease(AD):Factsataglance
• Every65secondssomeoneintheU.S.developsAD.
• ADisthemostcommoncauseofdementia;accountingfornearly70%ofalldementiadiagnoses.
• 5.8millionAmericanshaveadiagnosisofAD.
• Womenare2/3rdsofAmericanswithAD.
• AD–6thleadingcauseofdeathintheU.S.1in3seniorsdieswithADoranotherdementia.
Katzman(1998);Alzheimer’sAssociation(2019);Plassmanetal.,20076
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California:ADataglance
Estimated#ofseniorswithAD670,000
Expectedchangein%by2025 25.4%
840,000
http://www.alz.org/facts- Custom data for CA 28
Michigan:ADataglance
Estimated#ofseniorswithAD190,000
Expectedchangein%by2025 15.8%
220,000
http://www.alz.org/facts-CustomdataforMI29
Source:http://www.worldalzreport2015.org/
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Types of Dementia
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AD:HistoricalPerspective
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AugusteDeter–1stknowncaseofAD
• 51yearsold• Dramaticlossofmemory• Difficultysleeping• Disorientation• Delusionalthinking• Problemswithspokenandwrittenlanguage
• Diedat56
Dr.AloisAlzheimer
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2abnormalstructures:Beta-amyloidplaquesDenseproteindepositsthataccumulateoutsideandaroundneuronsNeurofibrillarytanglesTwistedfibersoftauproteinthatbuildupinsideneurons
Cellular/molecularchangesinAD
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AD:Neuroimagingfindings
1. Cortexshrivelsup.
2. Severeatrophyinthehippocampus.
3. Enlargedventricles.
4.Reducedregionalbrainmetabolism.
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AD:Progressionofneuropathology
Severedementia
ModeratedementiaMilddementia
http://www.alz.org/alzheimers_disease_4719.asp 36
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• Episodicmemory:Earliestandmostseverelyaffected• Attentionandworkingmemoryimpairmentsappearearly• Disorientationtotimeandplace• Languagedeficitsinnaminganddiscourseintheearlystages,
withphonologyandsyntaxspared• Semanticknowledgesparedearlyon,butdeteriorates
eventually• Impairmentsofexecutivefunctionandvisuospatialability.
AD:Cognitive-linguisticperformance
Bayles,1991;Bayles&Tomoeda,2007;Hickey&Bourgeois,2018;Genova,2009 37
KN:78/F,YrsEd:16,formernurse
MedicalHistory:Hypertension,hypothyroidism,gout,osteoporosis,priorhistoryofbreastcancer.
MiniMentalStateExamination 20/30(norm=27)GeriatricDepressionScale-ShortForm 1/15NotDepressedDementiaRatingScale-2ndED(DRS-2)
– Initiation/Perseveration-2ndpercentile– Memory-<1stpercentile– Constructionalability–41st–59thpercentile(borderline)– Semanticmemory–90thto94thpercentile– Attention–72nd-81stpercentile
ArizonaBatteryfortheCommunicationDisordersofDementia(ABCD)
Totalscore=12.3Consistentwithmoderatedementia
CaseProfile1:Alzheimer’sDisease
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AD:ClientProfileGenerativenamingforANIMALS: 10Animals….thepigjumpedoverthehorse,thehorseranunderthecow,the
dogbarkedatthecat…,donkey,mountainlion,buffalo,owls,snipes.
Confrontationnaming 14/20ontheABCDFluentsentence-levelspeech:Word-findingdifficulty,ideationalrepetition,useofvaguereferents(e.g.,stuff,thing),noparaphasiasnorfranksyntacticerrors.Noevidenceofapraxiaordysarthria.
Auditorycomprehension:Commands/questions 11/15(ABCD)
RepetitionSubtestsontheABCD: 58/75
Discourse:ABCDSubtests-Objectdescription,Picturedescription,storyrecall
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AD:ObjectDescription
ResponseofahealthyolderadultLet’ssee…thisisacommonobjectthatmostpeopleuseforwritingordrawing.Itislongandslender,madeofwoodontheoutside,andhasleadorgraphiteinthecenter,whichisthematerialthatmarkspaperandisusedforwritingonpaper.Pencilsusuallyhaveaneraserononeendandaleadpointattheotherwhichcanbesharpened.Pencilscomeinallsizesandcolors,arenotatallexpensiveandyoucanbuythematmoststores.Thesedaysyouhavemechanicalpencilsthatneedn’tbesharpened.ResponseofthispersonwithADThisisjustapencil,likeanyotherpencil.Ihaveseveralofthoseasdomostpeople.That’showIwoulddescribeit.
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AD:Clientprofile
TargetFigureonMMSE
ClientAttemptClockDrawing
MMSEItemWriteasentenceofyourchoice
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AD:PictureDescriptionOkay…Iseeapicture.Anicepicturebutnotincolor.Alady….probablythemotherhere…busywiththisthinghere(pointstodishinherhand).She’sbusywashingdishesbutnotpayingattention….toherkids…ortothedishes.Thesechildrenhereareeatingtoomanycookies…isitcookiesorcandy?YesIseethewordscookiejar.Soheretheyareeatingcookieswithoutaskingmother.Thislittlefellamay...whatelse?Doyouhaveotherquestionsaboutthispicture?It’sapictureofaregulardayinthekitchen.Andthesefellastakingcookies,andthisone(pointstolady)doingherstuff.She’susingalotofwater!Iwouldn’t.
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VASCULARDEMENTIA(VAD)
VaDcompeteswithLewybodydiseaseasthe2ndmostcommoncauseofdementia,afterAD.
National Institute on Aging, 2003; Bayles & Tomoeda, 2014
Vasculardementia(VaD)
ReferredtoasVaDorVascularCognitiveImpairment(VCI)– Accountsforapproximately10%ofdementiacases.– M>F– VCIsharessimilarriskfactorsasstroke-AFib,HTN,DMTypeII,Hypercholesterolemia
Lifestylefactors:Alcoholabuse,smoking,Lackofphysicalactivity– PriorHxofCVA=9xincreasedriskofVaD– Associatedwithvascularpathology(corticaland/orsubcortical)andastair-stepprogression
VaDinvolvesthesuddenonsetofanyofthefollowingsymptoms:
• Confusionandepisodicmemoryimpairments• Wanderingorgettinglostinfamiliarplaces• Rapid,shufflinggait(historyofunsteadinessand/orfalling)
• Lossofbowelorbladdercontrol• Emotionallability• Difficultyfollowinginstructions• Problemshandlingmoney
VaD:Presentingsymptoms
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• LesspredictablethanAD• WorseperformancethanADonattention,visuospatial
function,executivefunction,andletterfluencytasks.• Moreperseverativebehaviorandapathyobserved
earlierindiseasecourse• Betterperformanceonimmediateanddelayedrecall
thanAD.• SimilarperformanceaspersonswithADontasks
involvingworkingmemory,language,processingspeed,andconstructionalpraxis.
VaD:Cognitive-linguisticperformanceandcomparisonwithAD
Mahendra & Engineer, 2009; Bayles & Tomoeda, 2014
VaD:ClientProfileBG:82/M,YrsEd:14,biracial(Caucasian/Latino)MedicalHistory:Hypertension,TIAs,Frequentfalls,Myocardialinfarctionover10yearsagoMiniMentalStateExamination=13/30 (norm=27)DementiaRatingScale-2ndED(DRS-2)
– Initiation/PerseverationandMemory-below1stpercentile– Constructionalabilityandsemanticmemory–41st–59thpercentile(borderline)
– Attention–19thto28thpercentile
RepeatableBatteryfortheAssessmentofNeuropsychologicalStatus(RBANS)
– Below5thpercentileonall5domains-Immediatememory,Visuospatialability,Language,Attention,andDelayedmemory.
VaD:Neuroimagingfindings
AxialprotondensityMRIshowingwhitematterlesionsandratings(A) Normalcontrol(PVHscore=0;WMH
score=0)(B)Patientwithvasculardementia(PVH:frontalcaps=2,occipitalcaps=2;WMHfrontal=5,parietal=6
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VaD:Clientprofile
Mahendra&Engineer,2009
TargetFigureonMMSE
ClientAttemptClockDrawing
MMSEItem:Writeasentenceofyourchoice.
VaD:ClientProfile
GenerativenamingforANIMALS“Ineverthinkofanimals.There’smillionsofanimalsandIcan’tthinkofoneofthem.Lion…tiger…cats..dogs.Alltheanimalkingdom,wherevertheyare…lion,tiger,cats,dogs.Everyanimalonearth,becauseeveryanimalisansweredbythatquestion.”
Confrontationnaming:11/20ontheABCD
Fluentsentence-levelspeech:Emptyspeech,ambiguoussentences,pauses,word-findingdifficulty
Auditorycomprehension:Commands+questions:11/15(ABCD)
Repetition:39/75(ABCD)Discourse:Objectdescription,Picturedescription,storyrecall(ABCD)
VaD:PictureDescriptionIseesomecookiesthey’rerobbinginthejar.Somekidsrobbingthecookiejar.Somechildrengonnahurtthemselvesstandingonachair.Theboyhas...isthataboyoristhatagirl?Oh...whatever…playingwithdangerstandingonachairreachingfor...mama’sdoingthedishes…theyshouldbedoingthedishes.Andtheyhaveaspill...adirtyspillthere(pointstowaterflowingoverthesink)…itlookslikeshe’sgonnagetherfeetwet.Ican’tmakeoutwhatthisis(pointsoutsidethekitchenwindowinthepicture)butitlookslikeagardenandoutsidehedge.AsIsaid,she’sdoingherdishes.
Mahendra&Engineer,2009
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ComparedtopersonswithAD,thosediagnosedwithVaDaremorelikelytohave:
– Abruptonsetandstepwiseprogressionofdeficits.– Documentedcardiovasculardisease,HTN,orCVA.– Evidenceofsubcorticaldysfunction(gaitdisturbance,historyofunsteadiness,historyoffrequentfalls).
– Typicallyearlieronsetofincontinence.– Worseperformanceonattention,verbalfluencytasksandgreaterperseveration.
DifferentiatingVaDfromAD
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FrontotemporalLobarDegenerationorFTLD
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FTLD
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CharacteristicsofFTLD• FTDsaccountforabout10%ofallpersonswithdementia.
• B/w4to20%ofPWDatmemorydisorderclinicsarethoughttohaveanFTD.
• 12%ofpersonswithonsetofdementiabeforeage65haveanFTD.Usuallydevelopsbetweenages35-75years.
• Rapidlyprogressive;hasa2to10yeardiseasecourse.• Stronggeneticcomponent;positivefamilyhistoryin20-40%of
cases.Hallmarksymptom:Gradual,progressivedeclineinbehaviorand/orlanguage.
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AssociationforFrontotemporalDegeneration(AFTD)
TypesofFTLD
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Frontotemporaldementia
Behavioral variant
Language variants – Primary
progressive aphasias (PPA)
Semantic Variant (fluent) sv-PPA
Nonfluent or agrammatic
variant nfv-PPA
Logopenic PPA
l-PPA
Motor variants
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FTD:Symptomsvarybysubtype• Gradualchangesinpersonalityandsocialbehavior• Uninhibited,sociallyinappropriatebehaviors• Compulsiveorrepetitivebehaviors(handwashing,
pacing)• Lossofconcernaboutpersonalappearance/hygiene• Inappropriatesexualbehavior(hypersexuality)• Increaseinappetite(constanteating,wtgain)Emotionalsymptoms• Apathy,lossofdrive,socialwithdrawal,lackofempathy
LanguagechangesinPPA• Lossofspeechandlanguage
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FTDaffectsthefrontalandanteriortemporallobesofthebrainor”executivefunction”centers.
FTD:Neuroimagingfindings
Seelaaretal(2010)JNeurolNeurosurgPsychiatry
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LogopenicPPA:CaseProfile
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ASHA’sPositionontheRoleofSLPsinDementiaManagement
• Thatwe“playaprimaryroleinthescreening,assessment,diagnosis,treatment,preventionandresearchofcognitive-communicativedisordersindementiaandrelatedconditions” and
• “aprimaryroleinthescreening,assessment,diagnosis,treatment,andresearchofswallowingdisordersindementia.”
ASHA(2005)
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UnderstandingDisability
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MedicalModel:Thepersonwiththedisabilityisperceivedastheproblem
SocialModel:Thepersonwiththedisabilityisnottheproblem;structuresandsystemsin
societyaretheproblem
WellnessandDisabilityforpersonswithdementia
• WorldHealthOrganization’sInternationalClassificationofFunctioning(WHO,2001)
• BASICSBiopsychosocialModel(Ronch,1987;Vickers,1974)
• LifeParticipationApproachtoAphasia(LPAA)(Kagan,Lyon,Elman,Bernstein-Ellis,Chapey,SimmonsMackie,2000)
• Personhood(Crisp,1999;Kitwood,1997;Kitwood&Bredin,1992)
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ContextfortheWHOmodel
LifeParticipationApproachforDementia
Forme,somethingpivotalhappenedbeforetheICF(2001)and
LPAA(1999)models
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BASICSBiopsychosocialmodel
Needs Outcomesofaddressingspecificneed
B-Biological Senseofstrength/security/safety
A-ADLs Senseofindependenceandcontroloverimmediateenvironment
S-Societal Senseofuniqueidentityandself-worth
I-Interpersonal Opportunityforsocialroleexpressionandconfidence;tobecaredforandtocareforothers
C-Creative Useofsparedabilities;supportsindependentactivitiesthatprovidestimulation.
S-Symbolic Senseofhope,self-actualization,andself-fulfillmentdespitelossofselfgivendementia
Mahendra&Arkin,2003;Ronch,1987;Vickers,1974
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Elder Rehab 1996-2001 NIA
ETAC-Alzh Assoc. 2005-2010
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PersonhoodCrisp,1999;Kitwood,1997Kitwood&Bredin,1992
• Personhoodcountersthetendencytoassociatelossofcognitiveabilitywiththelossofbeinghuman.
• Whatmakesushumanisnotjustcognitivedimensionoffunctioning,butalsoourimaginative,social,expressivedimensionsofbeing.
• Barich(1998):‘Youbecomeapersonwhenyouenterintorelationwithotherpeople’.
4principlesofperson-centeredcare
Logotherapy
ViktorFrankl
Raisond’être
Ikigai
LifeParticipation
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Point:HistoricfocusonimpairedabilitiesinPwD
• Therapeuticnihilism(Clark,1995).
• Exclusivefocusonprogressivenatureofdementia.
• Insufficientemphasisonvariationindiseasetrajectory,andfunctionbystageofseverity.
• Rudimentaryunderstandingofhumanmemorysystems.
• Researchondementiamanagement-heavilybiasedtowardsdrugdiscovery.
• Reimbursementchallenges(esp.intheU.S.)
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Counterpoint
• Dementiaisaglobalepidemic.
• Distinctdementiaswithspecificpatternsofprogressions.
• Sophisticatedunderstandingofhumanmemorysystems,neuroplasticity,andQoLwithprogressivedisease.
• Burgeoningevidenceforsparedabilitiesindementia–leadingtomorenuancedassessmentofPWDs’potentialandresponsetointervention.
• Growingresearchandevidence-baseforefficacyofseveraldirectinterventions.
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Person-CenteredAssessment
MemoryModel(Bayles&Tomoeda,2015;Mahendra&Hopper,2017;Squire&Zola-Morgan,1991)
S E N S O R Y
WORKING MEMORY or ACTIVE MEMORY L
____________________________________________________ O Recall System Learning-by-Doing System N DECLARATIVE NONDECLARATIVE G T
Semantic Episodic Lexical Procedures Habits Priming Conditioned E Responses
R M
Motor Cognitive
Skills Operations
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Skilledassessmentindementiaisinformedby:
• Client’ssetting• Evidencebase• Understandingofsparedandimpairedabilitiesindementia• Useofdynamicassessmentprotocols(e.g.,test-teach-
retest)
Bayles&Kim(2003);Hickey&Bourgeois(2018)Hopper,Bayles,&Kim(2001);Mahendra&Hopper(2017)
OpportunitiesinAssessment
• Quantifyseverityofcognitiveandcommunicativefunction.
• Documentsparedandimpairedabilities
– Usevariedassessmenttools(e.g.standardizedtests,observation,interview,scales)
– ConsiderstrengthsandlimitationsofstandardizedtestswhentestingdiverseOA(e.g.useage-andeducation-correctednorms).
OpportunitiesinDynamicAssessment
Assessingbeyondfreerecallofstimuli:Cuedrecall,recognition,andfamiliarityassessment.Presentingstimuli/instructionsindifferentmodalities.(Mahendra,Bayles,&Harris,2005;Mahendra,Engineer,&Caroll2009)Demonstrateclientabilitytobenefitfromskilledtx.
Bourgeois,2007;CentersforMedicareandMedicaidServices,2001;Hickey&Bourgeois,2018;Mahendra&Hopper,2017;Tomoeda,2001
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SuggestedAreasforScreening
Medical history Self or CG report of
memory problems
Hearing and Vision impairments
Depression
Cognitive function
Polypharmacy
Screening&Assessment:StandardizedTestsSCREENING
Age-andeducation-correctedMMSE(Crumetal.,1993;MMSE-2;MMSE-EV)
MontrealCognitiveTest(MoCA;Nasreddineetal.,2005)
VASt.LouisUniversityMedicalSchoolExamination(SLUMS)
ASSESSMENT
DementiaRatingScale-2(Mattisetal.,1991)
RepeatableBatteryfortheAssessmentofNeuropsychologicalStatus(RBANS;Randolphetal.,1998)
CognitiveLinguisticQuickTest(CLQT;Heml-Estabrooks,2001)
ArizonaBatteryforCommunicationDisordersofDementia(ABCD-2Bayles&Tomoeda,2019)
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StandardizedAssessments–GoneFunctional
RatingScales
• ADLsandIADLs• Functional
Communication
ProblemBehaviors• StructuredObservation• BehaviorLogs(frequencyofbehaviors)
DiscourseMeasures• Picture
Description• ObjectDescription• ConceptDefinition• Conversational
Prompt
My Children
I have 2
daughters: Sandra and
Denise
Bourgeois,2007;Hickey&Bourgeois,2018;Brushetel.,2012
IncorporateAAC
www.talkingmats.com
GreyMattersapp
TalkingPhotoAlbums
SceneandHeardapp
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Client
TypesofInterventionsforPersonsWithDementiia
DirectInterventions IndirectInterventions
1. Environmentalmodifications
2. Caregivertraining
CGMahendra(2001);Hopper(2001);Bourgeois&Hickey(2009),Mahendra(2010) Client
Yet…
Useknowledgeandskillstodetermine:• Whichclientisacandidatefordirectvs.indirectinterventions?
• WhatoutcomemeasuresreflectthenewlearningthataPWDcandemonstrate?
• WhatdoesittakeforanSLPtobecomeskilledatimplementingdementiainterventions?
PrinciplesforSuccessfulIntervention1. Strengthenmemorytraceswithrepetition.
Useitorloseit Useitandimproveit2. Usesparedabilitiesandactivelyengagethenon-declarative
memorysystemduringlearning.3. Reduceerrorsduringlearning.4. Designinterventionssopatientsfocusattentiononasingle
task.5. Usesalientcuesandtangiblesensorystimulitoaidrecall.6. Returnaccesstothepleasureofcreativearts.
Mahendra,N.(2001);Bayles&Tomoeda(2007);Mahendra&Apple(2007);KleimandJones(2008),Mahendra(2011);Hopperetal.(2013)
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TargetwellnessforPWDinourclinicalinterventionsby:
• Emphasizepersonhoodandtheneedtofeelneeded
• Allowautonomyandcreativeexpression
• Providemeaningful,stimulatingactivities–physical,cognitive,andsocial
Intervention1:SpacedRetrievalTraining(SRT)
• Memoryshapingprocedurethatreferstosuccessfully
practicingrecallofinformationorastrategy/procedureoverprogressivelylongerintervalsoftime.
• Clinicianasksaquestionandrequiresanimmediateresponse(verbalormotor)fromtheclient.
• Intervalbetweenrecallopportunitiesislengthenedovertimeuntiltheclientdemonstratesrecallofinformationforclinicallysignificantamountsoftime.
Brush&Camp(1998);Hopper,Mahendra,etal.(2005),Hopperetal.(2013)
SRT:AshapingparadigmTrainingsuccessfulrecallovergraduallyincreasingtimeintervals
Newinformationpresented
Incorrectrecall
Incorrectrecall
Incorrectrecall
Incorrectrecall
2min
4min
8min
16min
32min
Correctrecall
Correctrecall
Correctrecall
Correctrecall
Brush&Camp(1998b);Cherry,Simmons,&Camp(1999);Mahendra,2011;Hopperetal.,2013;
Mahendra,Scullion,&Hamerschlag,2011;Vance&Farr(2007)
WhydoesSRTwork?
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SRTExamples
1.FallPrevention/SafeMobilityClinician:“BeforeyoustandIwouldlikeyoutolockyour wheelchairlikethis.Whatshouldyoudobeforeyoustand?”Client:“Ishouldlockmychair.”2.SafeswallowstrategyClinician:“Beforeyouswallowwater,Iwouldlikeyoutotuckyourchinlikethis.Whatshouldyoudobeforeyouswallowwater?”Client:“Tuckmychin.”
Brush&Camp,1998b;Brush,2003;Cherry,Simmons,&Camp,1999;Hopper,Mahendraetal.,2005;Leeetal.,2009,Hopperetal.2010;Mahendra,2011
Typesofinformationthatcanbetrained
• Compensatorystrategies– Usingacalendarorschedule– Learningasafetystrategy(e.g.,atransfertechnique)orasafeswallowstrategy(Brush&Camp,1998;Mahendra&Tomoeda,2009)
– Describinganobject(Abraham&Camp,1993)• Meaningfulinformation
– Roomnumber– Address– Face-nameassociations(Hawley&Cherry,2004;Mahendra,
Apple,&Reed,2008;Hopperetal.,2010)
Promotingcarryover
• ScheduleSRtaskswithinexistingprogramactivityperiodsortherapysessions.
• Alwaysendsessionwithasuccessfulresponse.• TeachCG,volunteers,visitingfamilymemberstoimplementSRT.
• CriticalforeveryonetobeCONSISTENT–usethesamecue,acceptthesameresponse.
• HelpstorecordshortdemoclipsforprofessionalandpersonalCGs.
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ModificationstoTraditionalSRTMahendra,2011
• Usingcomputer-assistedvideo-enhancedSRT
Laptop/smart phone and video clips of procedure
Clinician assistance
SRT as learning modality
Errorless instruction
Intervention2:Memorybooks/wallets
• Oneofthebestvalidatedstrategiesformaximizingverbalcommunicationandretentionofpersonalbiographicalinformation
• Positivetreatmentoutcomeswhenusedbycliniciansaswellas
personalandprofessionalcaregivers
• Useofmemoryaidsisassociatedwith:– Improvedrecallofpersonalbiographicalinformation– independentinitiationofconversation– Improvedrecallofcompensatorytechniques– Reducedfrequencyofundesirablebehaviors– BettercommunicationbetweenprofessionalCGsandPWD
Bourgeois,1990;Bourgeois&Mason,1996;Johnson,1997
WhydomemoryaidsworkforPWD??
• Emphasizetangiblesensorystimulithatreducerelianceonepisodicmemory
• Usepersonallyrelevantandmeaningfulstimuli• Offerabilitytocontrolthetypeandamountofinformation• Allowformatflexibility–a8½x11book,asmallwallet,a
photoalbum,adigitalphotobook• Makeusingamemoryaida‘routineprocedure’andnested
withineverydaytasks
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Memorybookstimuli
MyChildren
Ihavetwodaughters–SandraandDenise.
My Home
IliveinSanJose,CaliforniaMyaddressis110ParkmeadowDrive.I’velivedherefor20years.
Somepointersforcreatingandusingmemorybooks
• Haveacleartherapeuticgoalforusingamemorybook(e.g.,initiateverbalcommunicationaboutactivitychoices,toretainsafeswallowstrategies).
• ForhighfunctioningPWD,designingamemorybookcanbeacollaborativeandcreativeprocess.
• Considerusingadigitalcamera,desktoppublishingsoftware,BoardmakerorPIcCollageformakingmemoryaids.
• Usekeychainwalletsthatcanbeattachedtoabeltloop,walker,purse,etc.
Intervention3:ReadingRoundtable
• Montessori-basedgroupactivity,aimedatincreasingpositiveengagementandverbaldiscussion
• PrecededbydevelopmentofQuestionAskingReading(QAR)• Structuredreadinganddiscussionactivitythatuses
specificallydevelopedstories,designedandadaptedwitheaseofcommunicativeaccessinmindforPWD
• Storieshaveasupportivesensoryformat(e.g.largefont,high-contrast,durablebookcovers)andlayout(e.g.,single-sidedprinting),interestingfacts,andaccompanyingcues/questions
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https://www.youtube.com/watch?v=z54ZWs1l1oc
WhydoesReadingRoundtableworkforPWD?
• Primesinformationusingstructuredrepetition• Supportsretrievaloflearnedinformation• Positivelyengagesresidents(e.g.inselectionofstory
ortexttopics)and• Emphasizesgroupprocedureandlearning-by-doingof
takingturnstoreadandanswerquestions• Utilizesrelativelysparedoralreadingskills• Fostersreminiscence
Intervention4:Music-basedIntervention
• Philosopherscalledmusicthequickeningart.
• “Ifyou’reoutofit,musicawakensyouandbringsyoubackintoit”. OliverSacks:Musicophilia
• Music-basedinterventionsfulfillsocial,interpersonal,
creative,andsymbolicneedsofPWD.
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Music-basedInterventions
• PWDrequireaccesstopleasant,stimulatingactivities,ifwewanttoreducenegativebehaviors.
• PWDneedtobeactivelyengaged,stimulated,andtobecreative.
• Musicimprovescommunication,mood,socialization,andrecallofbiographicalmemories.
• SingingandperformingcanempowerPWDbymakingthemfeelproductive,andallowingthemtouseskillstheyhave.
InterventionPrinciples
• Incorporatestructuredrepetition,rehearsal,consistentsessionformat.• Establishroutinesandinvokeproceduralmemory.• Usesupportedconversationandmultimodalcueing.• Organizesessionsintoconceptualthemes;engageresidualsemantic
memoryviareminiscence.• Trackvariedoutcomes;includestaff-andresident-reportedsocial
validation.• Encouragegroupautonomyinsong/themeselection;allowgroupidentity
todevelop.• Trainstaffactively;providesupports;removebarrierstoimplementing
intervention.
SocialValidationOutcomes:NarrativevoiceofPWD
“Doingthiswaslikegettingoutofthedungeonandintotheclouds”.
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“Half-waythere”BonJovi
• Questions?• ThankyouWMU!
[email protected]@sjsu.edu@NidhiMahendra
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