Eva* was one of the many patients on my schedule to treat in a small town skilled nursing facility, one where families are present on a daily basis, individuals from the community volunteer to provide meaningful activities, and you really do get the sense that everybody knows everybody here.
Eva, however, could rarely tell us her last name, what year it was, what she ate for breakfast 30 minutes prior, or any activity that she “used to enjoy.” I was asked to assess her swallow function.
Step one for a swallowing evaluation is to have the patient sit at 90 degrees. Eva was having no part of it. Lying in her bed at 35% looking at the ceiling was her agenda for the day, unless I would agree to give her a Diet Pepsi. She could not tell me her last name, but she could command “Get me a Diet Pepsi.” Eva won, and off to the therapy gym we went, with Eva sitting nicely at 90 degrees in her wheelchair.
Immediately before we entered the gym, another spontaneous statement, “Is that a piano?” she asked “Yes,” I responded a bit shocked that she had voiced a cohesive full sentence, “Beautiful piano, however I only see groups play on Sundays.” In therapy, Eva was able to complete the assessment. But getting her to follow commands was challenging and at best she was able to answer closed ended “yes” and “no” questions. The Pepsi, of course, was the only reason she agreed to see me.
Again as we exited the gym she asked, “Is that a piano?” I had a sense that this question was more than repetitive questioning we often see in individuals with dementia and so I moved the stool from in front of the piano, pushed Eva forward and opened the keys. She fumbled around for a few seconds and then, like the memory had been permanently etched in her memory, she broke out into a flawless version of “Old Rugged Cross”, then “How Great Thou Art”, and finally “In the Garden.”
The room was silent; some of the staff who had known her for years was in tears. I will never forget that moment. This is the beauty of procedural memory and its ability to remain intact into the later stages of dementia.
By 2050, the number of people age 65 and older with Alzheimer’s disease may nearly triple, from 5.1 million to a projected 13.8 million, barring the development of medical breakthroughs to prevent or cure the disease.
Providing care to individuals with dementia can be a daunting, yet rewarding experience for caregivers in long term care communities, particularly during these “aha” moments when you are able to provide meaningful activities and communication exchanges. We know that dementia is not a specific disease; however it is an overall term that describes a group of symptoms associated with a decline in memory or other thinking skills severe enough to reduce a person’s ability to perform everyday activities.
Communication and changes in memory and a person’s ability to understand others and effectively communicate wants, needs and ideas is a general theme when individuals are initially diagnosed with various forms of dementia and continues to decline as the disease process progresses.
Having an adequate understanding of these changes and best methods for promoting communication can be essential for having meaningful exchanges. In particular, abilities based approaches can be beneficial and achieve a focus on what individuals can do versus what they can no longer do.
Memory can be impacted for recent events with periods of misplacing objects; however individuals often have intact habit and procedural memory and can reminisce (long term memory) therefore designing meaningful activities around intact memories versus focusing on “can you remember?” or “why don’t you remember?” more recent activities can be beneficial.
May present with disorientation for time, however can maintain orientation to person and place therefore implementing a calendar system with review as part of the morning routine can be beneficial.
Sequencing complex activities can result in difficulty ordering aspects of the task, however often time individuals can order similar and familiar activities, therefore keeping activities of daily living routines consistent in nature can reduce confusion for the individual and caregivers and also allow for greater levels of independence.
Communication “blocks” can be frequent during conversational interactions, however individuals can still express needs and are often more successful when conversions are topic structured versus spontaneous in nature.
Individuals at this level can be highly distractible and will often switch from one topic to another; therefore having the communication partner focus on single topic, or provide examples and repetition of topic can be helpful.
Comprehension of multiple steps can be challenging, however individuals may be able to follow two-step directions therefore breaking down ADL tasks to this level can increase success.
Problem solving skills at this level can be greatly impacted; however the individual can be successful with verbal cueing from caregivers.
Often individuals present with severely impaired orientation to person, place, time, environment and body parts, however will often know their name and can respond to common greetings. Therefore caregivers should continue to always refer to the individual by name and greet daily.
Greatly impacted memory functioning for short term, long term memory and semantic memory (word finding skills), however often has preserved procedural memory.
Difficulty responding to open ended questions such as “What would you like to drink?” However may be able to respond to a “Yes” and “No” question, therefore having caregivers alter communication approach is crucial.
In closing, for all of the Evas you encounter on a daily basis I ask you pay attention to those small moments to dig deep for memories and encourage communication. I guarantee what you hear may just be music to your ears.
*Name has been changed.
Renee Kinder, MS, CC-SLP, RAC-CT is a clinical specialist at Evergreen Rehabilitation in Louisville, KY. She serves on the American Speech Language Hearing Association’s Special Interest Group 15- Gerontology Perspectives on Gerontology Editor and as a Health Care and Economics Committee Member.