Treating cognition in the real world can be messy, due to many factors including incomplete information and lack of resources. But even so, cognitive-communication therapy can still be effective by focusing on your patient’s specific desired outcomes.
In an ideal world, you would have complete access to your patient’s medical history and current diagnoses when you meet them. You’d have ample time and resources to do a thorough assessment, make a detailed plan, and achieve all your goals.
I suspect that outside of a graduate school clinic, few of us have all of these things.
I’d like to share the story of a patient who came home from the hospital with a new diagnosis of “dementia” and how I handled working with her during the three weeks it took me to clarify what “dementia” meant. I’d love to hear from you if you would have done something differently!
Free DIRECT download: “Alphabet game” for language and cognition (patient handout). (Email subscribers get free access to all the resources in the Free Subscription Library.)
Outline:
- Meet my patient Rose.
- Assessing language and cognition.
- Establishing therapy goals.
- Education and strategies.
- Therapeutic exercises.
- Cognitively-stimulating activities.
- Dementia diagnosis and therapy outcomes.
- What would you have done differently?
- Related Eat, Speak, & Think posts.
Meet my patient Rose
Rose was 86 years old, married, and living with her daughter’s family. She recently had a short hospital stay for a possible TIA which caused transient dysarthria and right-sided weakness. Imaging was negative. During the hospital stay, she was diagnosed with dementia, but the available medical records did not elaborate. “Dementia” is a vague term and could apply to perhaps 18 different specific conditions.
Rose’s past medical history included hypertension and two previous TIAs over the past two years. Rose’s mother and older sister had both had Alzheimer’s type dementia, and her daughter was nervous about this new diagnosis.
Her family reported that she wasn’t as talkative as she used to be, had noticeable word-finding problems, was forgetful of recent events, and was having trouble writing checks out to pay her few bills. She now spent most of her day watching TV. Rose was aware of her difficulties and openly discussed them without any outward evidence of worry or embarrassment.
Even though I didn’t know what kind of dementia she had been diagnosed with, and I would ask her physician for clarification, I had to continue on with my assessment and treatment.
Assessing language and cognition
Since I no longer try to fix everything at once in therapy, I also no longer try to assess everything.
Instead, I try to select assessment tools based on my patient’s complaints, goals, presentation, and medical history. I’ll dig deeper with a patient who is very motivated to return to a prior level of function than I will with a patient who is relatively content with their current level of function.
In Rose’s case, she conveyed she was relatively content with how things were going. Although she wasn’t interested in dramatically improving her skills, she was willing to try some things to improve her language and memory. And her husband and daughter were very interested in improving conversation and finding things to do other than watching TV all day.
For these reasons, I bypassed doing in-depth assessments of cognitive-communication and language skills. Instead, I used the following:
- The auditory comprehension subtests of the Boston Diagnostic Aphasia Examination 3rd Edition (BDAE).
- The Boston Naming Test 2nd Edition Short Form.
- The Picture Narrative Task (Cookie Theft) from the BDAE.
- The Short Blessed Test (SBT) (aka the Short Orientation Memory Concentration Test).
Rose showed impairments on all the measures, including scoring a 12 which is in the “Impairment consistent with dementia” range on the SBT.
I chose these measures to establish that she had an impairment and to gain some useful insight into her language and cognitive-communication skills without being too demanding. I knew I could always choose to do further assessment at any point if I wanted more information.
Establishing therapy goals
My primary goals were to teach Rose and her family strategies to improve conversation and short term memory, find some exercises that she would find at least mildly interesting to do, and find cognitively-stimulating activities to replace some of her TV-watching time.
Short-term goals
- Given a topic of interest, patient will verbalize 3 key ideas via complete sentences with 80% accuracy given min cues for using word finding strategies to improve communication by [date].
- Patient will complete at least 2 cognitive-communication stimulation exercises with 80% accuracy independently to learn recommended strategies and improve attention and memory for daily activities by [date].
Long-term goals
- Patient will improve participation in conversation by stating 3 complete thoughts about a topic of interest in 4 of 5 opportunities independently by [date].
- Patient will improve participation in cognitively-stimulating activities by engaging in at least 1 activity or structured exercise per day, 5 days per week, with support of caregiver by [date].
Education and strategies
Education about “dementia”
Even though I was still waiting for clarification about what kind of dementia she had been diagnosed with, I did provide some reading material since Rose’s daughter was worried about the diagnosis.
I provided them with a free book from the National Institutes on Health called “Understanding Alzheimer’s Disease: What You Need to Know”, since this was the most likely form of dementia given her family history and no report of symptoms indicating a different form of dementia.
Attention strategies
- Talk or work in a quiet, well-lit setting.
- Do one thing at a time.
- Take your time.
- Read all directions before starting a written task.
- Double check your work.
- Save challenging work for when you are rested.
- Take breaks.
Communication strategies
- Turn off the TV or mute it when talking.
- Turn on the lights and face each other when talking.
- Get the other person’s attention before talking.
- Check that the other person understands.
- Don’t pretend to understand.
Word-finding strategies
For word finding, I taught Megan Sutton’s 10 strategies and provided Rose with a copy of Megan’s handout. The strategies are: delay, describe, associate, synonym, first letter, gesture, draw, look it up, narrow it down, and come back later.
Memory strategies
I also taught memory strategies, using the WRAP acronym which I read about somewhere. (Maybe another clinician’s notes?)
- Write it down.
- Repeat it.
- Associate it.
- Picture it (imagine it).
Therapeutic exercises
My goal in selecting exercises is to find something that isn’t too easy and isn’t too hard. I look for the Goldilocks Zone, which I place between 60% and 80% accurate with min to mod cues to start off with. As my patient learns the strategies, I pull back on the cues and adjust the difficulty of the exercise if required.
Conversation
In order to improve conversation, I taught communication and word-finding strategies and then provided opportunities to practice them.
I modeled communication strategies including a few bad examples. Then I engaged Rose in conversation using the Tactus Therapy Conversation app, which provides interesting photographs and question prompts.
This exercise also allowed us to practice using some of the word finding strategies during a structured conversation-level task. Then I extended the exercise to make it more naturalistic by asking her questions about her interests and past experiences.
Rose’s husband and daughter participated in the sessions. First by watching me model strategies, and then by trying them out when talking with Rose. We talked about things that interested Rose: her family, her history, and local events.
They didn’t have an iPad and weren’t interested in buying one, so I simply asked them when they could make the time to talk. They identified dinner as a time when they were together but not talking and made an effort to find things to talk about.
Word-finding
I supplemented conversation-based therapy with word-finding exercises. I’m not current on the research for word-finding (I’ll add that to my to-do list). But it seems reasonable that it should be possible to improve word-finding in conversation by doing word-finding exercises.
And ideally, I’d like to induce word-finding failures in my patients to give them an opportunity to practice their word finding strategies. Sometimes it’s too challenging for someone to learn word-finding strategies at the level of conversation; they need an easier task to start with.
I select word-finding exercises based on the level of impairment my patients are demonstrating. For some patients, I may only do conversation-based word-finding. For others, I may choose category-based exercises. And if my patient is really impaired, I’ll work on basic skills such as confrontation naming, antonyms, etc.
For Rose, I chose basic category member generation, for example “name 10 dinner foods”. I also provided what I call “the alphabet game“. Rose selected a topic (I provide a long list of “easy”, “medium”, and “hard” topics) and write it at the top of the page. Then she would think of one word related to that category that begins with each letter of the alphabet and write it down.
I taught her husband and daughter how to provide cues instead of giving an answer. The more work Rose does to retrieve a word, the better for improving her skills. And this was a joint activity between Rose and someone else, so it offered yet another opportunity for conversation!
Attention and memory
Using the newspaper
Rose liked to read the local section in the newspaper, but couldn’t report what she read after a short delay. So I used her newspaper for two different exercises. One for visual memory and one for memory of information read.
First, I asked her to study the details of a photo and prompted her to apply the repetition, association, and picture it (visualization) strategies. Then I covered the photo and asked her to recall the details. Once that was easy, I started giving her unrelated distraction questions before asking her to recall the details.
For the other exercise, I asked her to read a sentence or paragraph, discuss the details and apply the memory strategies, and then recall the details of what she read. Again, once that was easy, I gave her an unrelated distraction question before asking her to recall the details.
The distraction questions started off easy, such as reporting her full name or address and then progressed to harder recall questions. If I felt like the recall questions weren’t enough of a challenge, I asked her to complete a working memory task.
I began increasing the memory load in my therapy tasks after an interesting 2016 ASHA Convention seminar by Irene Minkina, Christos Salis, and Nadine Martin titled “Verbal Short-Term Memory Breakdown in Aphasia: Theory, Diagnosis & Treatment.” You can download their handout from ASHA’s Convention page.
Working memory exercises
For working memory tasks, I tend to ask my patients to reverse or otherwise alter the recitation of known sequences. Here are some working memory tasks we did:
- Start at 10 and count backwards by 2s.
- Count backwards by 2s from 20.
- Start at 50 and count backwards by 5s.
- Count backwards from 100 by 10s.
- Say the days of the week in backwards order.
Cognitively-stimulating activities
Paying the bills
Rose had always paid the bills in her family, and she wasn’t ready to give that up. She was aware that she was having trouble. Her daughter said that she would sit with the mail, checkbook, and calculator for a long time and not make much progress. Rose’s daughter was happy to take over the duty, but Rose still wanted to participate.
I offered to directly assess and treat the skills involved, but Rose and the family were hesitant. Plus, Rose had the new diagnosis of dementia so I wasn’t sure if the benefits of intervention would persist long enough to make a real difference long-term.
Instead, I applied the Montessori principle to paying the bills, teaching Rose’s daughter how to engage Rose in paying the bills. I told her daughter to break the task down into steps and ask Rose to complete each step (providing assistance as needed). I walked them through an example. Then I asked them to give it a try and report back to me how it went.
TV engagement
I’m not a fan of watching TV, especially just passive watching. But I know it’s a favorite pastime of many people. So I teach active watching, in which my patient engages with what they’re seeing.
I instructed Rose and her family to mute the TV during commercials and comment on what they just saw. For instance, it could be an opinion, a prediction, or reminiscing about some memory it brought to mind. Basically, anything that promotes thinking about what they’re watching and discussing it with someone else.
Cards and games
Finally, I asked Rose and her family questions about previous pastimes to identify some activity that they would be interested in resuming. It turns out that they used to play cards and board games, but they hadn’t done so in years. I recommended that they start again, to provide a social activity that engages various cognitive skills and promotes conversation.
Dementia diagnosis and therapy outcomes
Over the course of the month of therapy, I noticed that Rose improved her conversation from phrases and frequent abandoned sentences to full sentences. She also began initiating conversation more often, both during the session and at other times of the day according to her family. Rose used description and gesture when she failed to retrieve a word right away.
By the end of therapy, Rose was able to report at least one specific detail from the current newspaper. She was able to comment on what she recently saw on TV. And she was remembering specific things we had discussed in previous sessions in detail.
The family began playing Rummy, Uno, and Rose started playing Solitaire again.
With respect to paying the bills, Rose and her daughter had two sessions of working together over the course of the month. They reported that both sessions went well. Rose’s daughter walked her through each step, providing just enough direction or support for Rose to complete each task.
About a week before I discharged her (and two calls to her physician), I finally learned that she was diagnosed with Mild Cognitive Impairment and did not have a diagnosis of dementia. So I educated Rose and her family about MCI and recommended she continue with the exercises and activities we had set up.
Rose improved her scores on all measures, including scoring a 7 on the Short Blessed Test, which moved her into the “Questionable impairment” range.
I suspect that her years of daily TV marathons which replaced more interactive and cognitively-stimulating activities led to her performing at a lower level than her capability due to disuse. It’s possible that the month of therapy we did trained her to use her existing cognitive skills more fully, rather than actually increasing her cognitive ability.
Regardless, when I discharged, she was much more verbal and communicative, had better recall for recent events, and was engaging in a variety of social and interactive activities. Everyone was pleased with the outcome.
What would you have done differently?
I think if we could somehow clone a patient 10 times and assign 10 different speech-language pathologists, that we may well get 10 different treatment plans. I honestly don’t think that that is necessarily a problem.
Language and cognitive-communication are remarkably complex, and every pair of individuals interacts differently based on their personality, values, knowledge, and experiences. If therapy were cookie-cutter, it would be boring and predictable, and I question whether it would be skilled.
I’m very curious to learn what you may have done differently, because I’m always happy to modify and change what I do based on our evidence base and the experience of my colleagues. At least to consider it and maybe try it out!
So, what would you have done with Rose and her family?
Free DIRECT download: “Alphabet game” for language and cognition (patient handout). (Email subscribers get free access to all the resources in the Free Subscription Library.)
Related Eat, Speak, & Think posts
- 5 easy steps to remember names.
- Assess readiness to change for better therapy outcomes.
- Collaborative goal-setting to identify meaningful cognitive goals.
- Writing SMART memory goals for a reluctant patient.
- How to use spaced retrieval with errorless learning to improve memory.
- 18 free assessment tools for cognition.
Featured image by Anders Nord on Unsplash.
Lisa earned her M.A. in Speech-Language Pathology from the University of Maryland, College Park and her M.A. in Linguistics from the University of California, San Diego.
She participated in research studies with the National Institute on Deafness and other Communication Disorders (NIDCD) and the University of Maryland in the areas of aphasia, Parkinson’s Disease, epilepsy, and fluency disorders.
Lisa has been working as a medical speech-language pathologist since 2008. She has a strong passion for evidence-based assessment and therapy, having earned five ASHA Awards for Professional Participation in Continuing Education.
She launched EatSpeakThink.com in June 2018 to help other clinicians be more successful working in home health, as well as to provide strategies and resources to people living with problems eating, speaking, or thinking.
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