Not Cured … But Improved Conversational and memory supports can help maximize communication for clients with Alzheimer’s dementia. Features
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Features  |   June 01, 2016
Not Cured … But Improved
Author Notes
  • Tammy Hopper, PhD, CCC-SLP, is vice dean of graduate studies and research, Faculty of Rehabilitation Medicine, and a professor in the Department of Communication Sciences and Disorders at the University of Alberta. She is an affiliate of ASHA Special Interest Group 2, Neurophysiology and Neurogenic Speech and Language Disorders. thopper@ualberta.ca
    Tammy Hopper, PhD, CCC-SLP, is vice dean of graduate studies and research, Faculty of Rehabilitation Medicine, and a professor in the Department of Communication Sciences and Disorders at the University of Alberta. She is an affiliate of ASHA Special Interest Group 2, Neurophysiology and Neurogenic Speech and Language Disorders. thopper@ualberta.ca×
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Special Populations / Older Adults & Aging / Normal Language Processing / Attention, Memory & Executive Functions / Features
Features   |   June 01, 2016
Not Cured … But Improved
The ASHA Leader, June 2016, Vol. 21, 44-51. doi:10.1044/leader.FTR1.21062016.44
The ASHA Leader, June 2016, Vol. 21, 44-51. doi:10.1044/leader.FTR1.21062016.44
Mrs. W—an outgoing 70-year-old—was diagnosed with dementia three years ago. She lives at home with her husband, and can still bathe, dress and perform other self-care activities relatively independently. But lately she has become withdrawn and shows some anxiety in groups of people, often standing up to leave at awkward moments.
Her husband reports that she struggles to remember names of friends and family members, and cannot follow conversations. He worries that she will become increasingly isolated because of her anxiety and frustration in social situations, and he knows that this will have a negative effect on her health.
The fact is that there is no cure for Mrs. W’s dementia—the inevitable result of increasing cognitive impairment caused by Alzheimer’s disease, the progressive neurocognitive disorder. As her example shows, speech-language pathologists need to focus “treatment” on managing symptoms with the goal of decreasing disability and maximizing functional abilities.
For SLPs, however, traditional models of rehabilitation and goal-setting involve an expectation of improvement, or at least stability—not decline—in function. So, when working with people with Alzheimer’s dementia, SLPs may have questions about how to best approach treatment. In my experience, the key is to facilitate specific communication behaviors related to everyday activities and life participation.
A growing body of research evidence supports this approach. It is well known that all aspects of cognition and communication are not affected equally in Alzheimer’s dementia. Although declarative learning and effortful cognitive processing show impairment early in the disease, conceptual knowledge and procedural memory may remain intact until later (see sources below).
And although discourse production and comprehension deteriorate, people with the disease may retain many communication abilities, including the desire and need to interact with others (see the chapter I co-wrote with Nidhi Mahendra in the book “Aphasia and Related Neurogenic Communication Disorders”).
Given this knowledge of cognitive and communicative patterns in Alzheimer’s dementia, we can capitalize on relatively spared abilities while decreasing demands on more impaired ones. We will focus on interventions to use in three of these areas here. SLPs can combine them with communication-partner training to foster engagement, social interaction and well-being among people with dementia.
Written and graphic cues
Even in the early stages of Alzheimer’s dementia, prominent episodic memory impairments limit patients’ ability to initiate and maintain conversations. In addition, they often forget what has been said or done. As a result, they may be unable to act on recently presented information.
For example, Mrs. W can respond appropriately, nodding and verbally agreeing, to her daughter telling her that she will come for dinner on Sunday and share news of her granddaughter’s school concert. However, within seconds, Mrs. W has forgotten what her daughter has told her.
Written and graphic cues can make such information more permanent and accessible to people with dementia. These formats work because they recruit spared functions, such as reading and recognition memory. Written and graphic cues can take many forms, including memory wallets (and their larger counterparts, memory books), which University of South Florida SLP and dementia researcher Michelle Bourgeois pioneered for use with people with dementia in the early 1990s.

Memory aids can be tailored to each person’s needs and interests and can be modified as their cognition and language abilities decline.

What are they? Essentially, they’re a collection of sentence and picture stimuli designed to prompt recall of important people, places and events in the life of the person with memory impairment (see sources). They can help provide a focus for meaningful, on-topic conversations, which are a key activity of daily life. Indeed, research evidence supports using these aids to improve verbal communication across a range of cognitive impairment severity.
Other forms of memory aids include schedules, calendars and cue cards that detail steps for completing simple or complex tasks. For example, laminated cards could delineate the steps necessary for dressing or oral care activities.
Clinicians can also tap other types of memory aids to improve orientation and to modify challenging behaviors. For example, researchers have shown that people with dementia can learn to refer to written cards or wipe-off boards to remind themselves of dates, times and event details, lowering repeated question-asking (see sources below).
All memory aids can be tailored to each person’s needs and interests and can be modified their cognition and language abilities decline.
Reminiscence therapy
Through reminiscence therapy (RT), patients discuss past activities and experiences with another person or group of people, usually aided by tangible stimuli like familiar objects and photographs (see sources and a past Leader article on this topic). These discussions are meant to facilitate social engagement and well-being.
Topics for reminiscence can be related to general themes, such as music, cooking or sports. Or they can be related to autobiographical information from certain time periods or events in a person’s life, such as childhood or family weddings. Many people with dementia are able to access such memories and, with the support of a potent cue, can answer questions about, and elaborate on, those memories. In a recent group we conducted, we showed pictures of an old outdoor pool that had existed when the group members were young children living in the city. At the time, that pool was a well-known landmark. The photograph sparked memories of summer afternoons swimming at the pool, and a general discussion of outdoor activities of interest to each person.
Topics for reminiscence can be related to autobiographical information from certain time periods or events in a person’s life.
Given the technique’s reliance on communication, SLPs can play an important role. They may facilitate group RT sessions or act as consultants, assessing participants’ language and cognitive skills and determining verbal and nonverbal cues to help them initiate and maintain conversations. Data should include the nature and frequency of participants’ communication.
Research links RT with positive outcomes in cognition, mood and behavior among people with varying levels of dementia severity (see sources). More research is needed on outcomes related to meaningful communication.

Spaced-retrieval training is appropriate to use with people wwith dementia because it recruits conceptual knowledge and procedural memory—largely spared, at least during initial stages.

Spaced-retrieval training
Spaced-retrieval training (SRT) is a method of teaching information and behaviors to people with episodic memory impairments. Using it, clinicians present information to learners and ask them to recall that information over increasingly longer time intervals. The learning is highly constrained to minimize errors and conscious cognitive effort (see sources and past Leader articles on this method— one focuses on using SRT to help people with dementia enjoy their favorite foods, while the other shares insights from SLP Jeanette Benigas on using SRT to help people learn new behaviors).
SRT is appropriate to use with people with dementia because it recruits conceptual knowledge and procedural memory—largely spared, at least during initial stages. Impaired memory systems are not heavily taxed.
And research I and others have reviewed consistently links SRT with positive outcomes for learning targets such as names, schedules, tasks and safety procedures—including using mobility devices and locking the door before leaving the house (see sources below).
It is important to note that some people with dementia, even in early stages of cognitive decline, are not suitable candidates for this approach. More research in this area is needed. In the meantime, pioneering SRT researchers Jennifer Brush and Cameron Camp have provided an SRT screening tool—available in their workbook “A Therapy Technique for Improving Memory: Spaced Retrieval”—that can help determine if a client can benefit from this approach.

As impairment worsens, so, too, does the person’s communication and ability to recognize and repair breakdowns. Therefore, care partners need tools to modify their own communication behaviors.

Communication-partner education
In the early stages of Alzheimer’s, people with the disease may realize their forgetfulness and its effect on their communication with others. However, as their impairments worsen, so, too, do their communication and their ability to recognize and repair breakdowns. Therefore, care partners need tools to modify their own communication behaviors to compensate for their partners’ growing limitations.
According to some research (see sources below), communication strategies that can help people with Alzheimer’s—and that are often the focus of caregiver education programs—include:
  • Simplifying syntax.

  • Using a normal rate of speech.

  • Repeating and rephrasing.

  • Summarizing and using yes/no and choice questions versus open-ended ones.

When caregivers and health care professionals receive training in such strategies, people with dementia derive significant benefit, according to a research review led by Eva Eggenberger of the University of Klagenfurt in Vienna. The review found that communication skills training of caregivers and providers increased positive interactions between them and people with dementia, and significantly improved patients’ quality of life and well-being.
It’s also important that, as part of patient-centered care, caregivers and health care professionals use relational or connecting strategies (see sources) to share meaning or understanding with patients, and to reach out and recognize patients’ strengths and abilities. For example, we can encourage (rather than ignore) and invite (rather than insist) someone with dementia to participate in a conversation, all while using an adult tone of voice. These strategies ensure that our communication is focused on acknowledging the person, and not just on compensating for the communication disorder.
Although it can seem challenging to design goals for patients with dementia like Mrs. W and measure progress in the face of inexorable declines in function, it is not only possible, but also reasonable, to do so. The International Classification of Functioning, Disability and Health provides a framework that, if applied, helps to ensure a holistic approach to managing communication disorders of dementia.
Communication goals that are tailored to relationships between typical communication partners, like Mrs. W’s husband and daughter, and that capitalize on our clients’ strengths—in addition to meeting their needs—can make a real difference in their quality of life.
Writing Functional Goals for Dementia?

ASHA offers a person-centered guide to help at on.asha.org/dementia-goals. The guide is in compliance with the International Classification of Functioning, Disability and Health.

Sources
Bayles, K., & Tomoeda, C. K. (2014). Cognitive-communication disorders of dementia: Definition, diagnosis and treatment (2nd Edition). San Diego, CA: Plural.
Bayles, K., & Tomoeda, C. K. (2014). Cognitive-communication disorders of dementia: Definition, diagnosis and treatment (2nd Edition). San Diego, CA: Plural.×
Bourgeois, M. (2014). Memory and communication aids for people with dementia. Baltimore, MD: Health Professions Press.
Bourgeois, M. (2014). Memory and communication aids for people with dementia. Baltimore, MD: Health Professions Press.×
Brush, J., & Camp, C. (1998). A therapy technique for improving memory: Spaced-retrieval. Beachwood OH: Menorah Park Center for the Aging.
Brush, J., & Camp, C. (1998). A therapy technique for improving memory: Spaced-retrieval. Beachwood OH: Menorah Park Center for the Aging.×
Cotelli, M., Manenti, R., & Zanetti, O. (2012). Reminiscence therapy in dementia: A review. Maturitas, 72(3), 203–205. [Article] [PubMed]
Cotelli, M., Manenti, R., & Zanetti, O. (2012). Reminiscence therapy in dementia: A review. Maturitas, 72(3), 203–205. [Article] [PubMed]×
Douglas, N. F. (in press). Implementing best practice in the real world: Buy-in and authentic teams. In Johnson, P. (Ed.), Dementia and Cognition. Gaylord, MI: Northern Speech Services.
Douglas, N. F. (in press). Implementing best practice in the real world: Buy-in and authentic teams. In Johnson, P. (Ed.), Dementia and Cognition. Gaylord, MI: Northern Speech Services.×
Egan, M., Bérubé, D., Racine, G., Leonard, C., & Rochon, E. (2010). Methods to enhance verbal communication between individuals with Alzheimer’s disease and their formal and informal caregivers: A systematic review. International Journal of Alzheimer’s Disease.
Egan, M., Bérubé, D., Racine, G., Leonard, C., & Rochon, E. (2010). Methods to enhance verbal communication between individuals with Alzheimer’s disease and their formal and informal caregivers: A systematic review. International Journal of Alzheimer’s Disease.×
Eggenberger, E., Heimerl, K., & Bennett, M. I. (2012). Communication skills training in dementia care: A systematic review of effectiveness, training content, and didactic methods in different care settings. International Psychogeriatrics.
Eggenberger, E., Heimerl, K., & Bennett, M. I. (2012). Communication skills training in dementia care: A systematic review of effectiveness, training content, and didactic methods in different care settings. International Psychogeriatrics.×
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(1), 126–145. [Article] [PubMed]
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(1), 126–145. [Article] [PubMed]×
Mahendra, N., & Hopper, T. (2016). Dementia and related cognitive disorders. In Papathanasiou, I. & Coppens, P. (Eds), Aphasia and related neurogenic communication disorders, 2nd edition. Burlington, MA: Jones & Bartlett Learning.
Mahendra, N., & Hopper, T. (2016). Dementia and related cognitive disorders. In Papathanasiou, I. & Coppens, P. (Eds), Aphasia and related neurogenic communication disorders, 2nd edition. Burlington, MA: Jones & Bartlett Learning.×
Small, J., & Perry, J. (2013). Training family care partners to communicate effectively with persons with Alzheimer’s disease: The TRACED program. Canadian Journal of Speech-Language Pathology and Audiology, 36(4), 332–350.
Small, J., & Perry, J. (2013). Training family care partners to communicate effectively with persons with Alzheimer’s disease: The TRACED program. Canadian Journal of Speech-Language Pathology and Audiology, 36(4), 332–350.×
Woods, B., Spector, A., Jones, C., Orrell, M., & Davies, S. (2005). Reminiscence therapy for dementia. Cochrane Database of Systematic Reviews, 18(2), CD001120.
Woods, B., Spector, A., Jones, C., Orrell, M., & Davies, S. (2005). Reminiscence therapy for dementia. Cochrane Database of Systematic Reviews, 18(2), CD001120.×
World Health Organization (WHO; 2001). International Classification of Functioning, Disability and Health. Geneva, Switzerland: WHO Press.
World Health Organization (WHO; 2001). International Classification of Functioning, Disability and Health. Geneva, Switzerland: WHO Press.×
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June 2016
Volume 21, Issue 6