Guest Columns

Use of the life participation approach for those with dementia

Becky Khayum
Becky Khayum

“How can therapy help an individual with dementia? Their condition will only get worse over time.”

“My mother with Alzheimer's/dementia has no problems with her speech . . . why has she been referred for speech therapy services?”

These questions are frequently posed to speech-language pathologists working with the geriatric population, particularly when working with individuals who are suffering from a neurodegenerative disease. As the general population continues to age, the number of individuals who will be diagnosed with Alzheimer's dementia or other dementia syndromes will continue to dramatically increase and will be appearing more frequently on an SLP's caseload. The question is: How can SLPs help to improve quality of life in this population, from diagnosis throughout the progression of the disease?

SLPs have extensive training in the areas of speech, language, swallowing, and cognition, including the areas of memory, attention, initiation, and sequencing. SLPs have traditionally been trained to use a “rehabilitation” approach for treating individuals with cognitive impairments caused by a stroke or traumatic brain injury, which focuses on testing the individual to identify deficits and then developing a plan of care to improve the areas of weakness. This approach is difficult to transfer to individuals experiencing progressive declines in language or cognition caused by a dementia syndrome.

The Life Participation Approach for Aphasia (Chapey, Duchan, Elman, Garcia, Kagan, Lyon & Simmons Mackie, 2000) provided a person-centered model of care, which focuses on an individual's ability to more fully participate in meaningful life activities, based on the World Health Organization's International Classification of Functioning, Disability and Health model. Although this approach is described specifically for individuals with aphasia, the principles of this approach can be applied to any diagnoses being treated by an SLP.

Let's take a look at how the LPAA model can be applied to dementia intervention. Assessment and treatment plans should target the following:

  • Developing treatment goals that target the patient's, family members', and caregivers' primary concerns.

  • Developing strategies that will facilitate the individual's ability to participate in meaningful, purposeful activities.

  • Addressing problem behaviors, such as agitation or repetitive questioning, through a nonpharmacological approach.

  • Taking advantage of preserved strengths to compensate for areas of weakness.

How does an SLP creatively integrate the life participation principles into evidence-based approaches for individuals with dementia?

Although cognitive workbooks, board games, and brain game apps may be stimulating for individuals with dementia, there is little evidence supporting the fact that these tasks will generalize to an improvement in memory and attention in daily functional activities. Here are the evidence-based interventions that have been supported by research in the field of speech-language pathology:

  • Creation of graphic and visual cueing systems—such as visual memory aids, memory books, and memory wallets—to help individuals recall any type of information that is important to them. Michelle Bourgeois and colleagues (Bourgeois, 1990) have established that different types of written and picture cues may be helpful throughout the course of Alzheimer's dementia, since the ability to read at the word and phrase levels remains a strength throughout the progression of the disease. Graphic cueing aids can help with the following:

  • Increased recall and initiation of daily activities

  • Increased recall of daily conversations and visitors

  • Increased recall of safety precautions

  • Increased ability to tell stories from the past

  • Increased recall of family and friends' names

  • Improved sequencing of activities of daily living and meaningful tasks (e.g., dressing, cooking, gardening)

  • Increased ability to communicate personal choices in addition to basic needs

  • Increased ability to comprehend conversation and follow directions

  • Decreased repetitive questions

SLPs can create personalized visual memory and communication aids with the patient during sessions through the use of brightly colored paper, index cards, and pictures from catalogues and magazines. For clinicians who have access to a smart tablet or laptop, aids can be created using pictures from the web or pictures of the patient's environment.

  • Use of spaced retrieval training to promote use of graphic cueing systems. Cameron Camp, Ph.D., and colleagues (Camp & Stevens, 1990) developed a program that takes advantage of an individual's intact procedural memory to recall targeted pieces of information at increasing intervals, such as the use of a visual memory aid.

  • Environmental Modifications: Jennifer Brush and colleagues (Bruce, Brush, Sanford, & Calkins, 2013) have investigated the impact that environmental modifications can have on the functioning of individuals with dementia. SLPs can work with occupational therapists to assess the patient's environment — including lighting, color schemes, flooring, furniture and hangings, and noise/sound — and then make the appropriate adaptations so the individual can function more independently and safely.

  • Communication Strategies: Many researchers have investigated the various types of communication strategies that family members and caregivers can use to positively affect the individual's ability to communicate. Researchers have shown that strategies such as avoiding questions that rely on short-term memory and asking choice questions instead of open-ended questions can increase an individual's ability to communicate in daily conversations and activities.

Case Example

A resident in a memory unit was reported to have problems of constantly attempting to leave the unit and repeatedly asking staff members when the next meal would be served. At times, the resident became combative when nursing staff attempted to lead him away from the elevator. With input from the memory unit nurses and nursing assistants, the SLP assessed the resident and developed the following plan of care:

  • The SLP indicated that the resident used to work in food services at a local cafeteria. Working with the memory unit staff, visual memory aids were created so that the resident could become involved in the following activities:

    • Helping to prepare simple snacks for the other residents and pushing around a cart to serve snacks in the morning and afternoon

    • Arranging flowers on each table for each meal and then wiping off the tables and putting the flowers away after each meal

  • A memory wallet was created, which contained information pertaining to meal times, daily schedule, and sequencing aids for snack preparation. SRT was used, and the resident frequently referred to his wallet when he became confused.

  • A memory book was created containing pictures from the Great Depression and other significant events from the individual's past. The staff was trained to use the book to redirect the resident when he was attempting to leave the unit. Because the individual's long-term memory was intact, he enjoyed discussing events from his childhood and was easily redirected.

Becky Khayum, MS, CCC-SLP is a member of the American Speech-Language-Hearing Association (ASHA) and its Special Interest Group 15 (Gerontology). Contact her at becky.khayum@memorycarecorp.com

References:

Bourgeois, M. S. (1990). Enhancing conversation skills in Alzheimer's disease using a prosthetic memory aid. Journal of Applied Behavior Analysis, 23, 29–42.

Bruce, C., Brush, J., Sanford, J. & Calkins, M.  (2013). Development and evaluation of the environment and communication assessment toolkit with speech-language pathologists. Seminars in Speech and Language, 34, 42-51.

Camp, C. J., & Stevens, A. B. (1990). Spaced-retrieval: A memory intervention for dementia of the Alzheimer's type. The Journal of Aging and Mental Health, 10, 58–61.

Chapey, R., Duchan, J. F., Elman, R. J., Garcia, L. J., Kagan, A., Lyon, J. G., & Simmons Mackie, N. (2000). Life Participation Approach to Aphasia: A Statement of Values for the Future. The ASHA Leader, 5(3), 4-6. doi: 10.1044/leader.FTR.05032000.4.

Duchan, R., Linda, J., Garcia, A. K., Lyon, J. G., & Simmons-Mackie, N. (2001). Life Participation Approach to Aphasia: A statement of values for the future. In R. Chapey (Ed.), Language intervention strategies in aphasia and related neurogenic communication disorders (4th ed., pp. 235–253). Baltimore, MD: Lippincott Williams & Wilkins.

Hopper, T., Bourgeois, M., Pimentel, J., Qualls, C. D., Hickey, E., Frymark, T., & Schooling, T. (2013). An evidence-based systematic review on cognitive interventions for individuals with dementia. American Journal of Speech-Language Pathology, 22, 126–145. Retrieved from http://ajslp.pubs.asha.org/article.aspx?articleid=1782723World Health Organization. (2001). International classification of functioning, disability and health. Geneva, Switzerland: World Health Organization.

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