Toss the Workbooks! Choose treatment strategies for clients with dementia that address their specific life-participation goals. On the Pulse
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On the Pulse  |   April 01, 2018
Toss the Workbooks!
Author Notes
  • Becky Khayum, MS, CCC-SLP, is co-founder and president of MemoryCare Corporation in Aurora, Illinois, which provides cognitive-communication interventions for people with neurodegenerative conditions. She is also an adjunct faculty member at Northwestern University and an affiliate of ASHA Special Interest Groups 2, Neurogenic Communication Disorders; 12, Augmentative and Alternative Communication; 15, Gerontology; and 18, Telepractice. becky.khayum@memorycarecorp.com
    Becky Khayum, MS, CCC-SLP, is co-founder and president of MemoryCare Corporation in Aurora, Illinois, which provides cognitive-communication interventions for people with neurodegenerative conditions. She is also an adjunct faculty member at Northwestern University and an affiliate of ASHA Special Interest Groups 2, Neurogenic Communication Disorders; 12, Augmentative and Alternative Communication; 15, Gerontology; and 18, Telepractice. becky.khayum@memorycarecorp.com×
  • Emily Rogalski, PhD, is associate professor and associate director of Northwestern University’s Alzheimer’s Disease Center. She directs NIH-funded research programs on “superagers,” primary progressive aphasia and neuroimaging biomarkers, and has developed educational programs, support groups and a telemedicine person-centered intervention to maximize quality of life for people with dementia. erogalski@gmail.com
    Emily Rogalski, PhD, is associate professor and associate director of Northwestern University’s Alzheimer’s Disease Center. She directs NIH-funded research programs on “superagers,” primary progressive aphasia and neuroimaging biomarkers, and has developed educational programs, support groups and a telemedicine person-centered intervention to maximize quality of life for people with dementia. erogalski@gmail.com×
Article Information
Special Populations / Older Adults & Aging / Attention, Memory & Executive Functions / On the Pulse
On the Pulse   |   April 01, 2018
Toss the Workbooks!
The ASHA Leader, April 2018, Vol. 23, 40-42. doi:10.1044/leader.OTP.23042018.40
The ASHA Leader, April 2018, Vol. 23, 40-42. doi:10.1044/leader.OTP.23042018.40
You arrive for work at your skilled nursing facility, assisted living community, memory care community or outpatient hospital clinic and glance at the long list of clients—many with a dementia diagnosis—on your schedule for the day. You wonder how you are ever going to fit everyone in while maintaining your 90-percent productivity expectation.
So you go on autopilot: You grab some standardized tests, along with some picture flash cards and a cognitive workbook from your file cabinet. With these tools in hand, you set out to treat your clients. We’ve all been there.
Many of us may often have left work thinking, “Did I really make a difference in the lives of my clients today?” Mr. Silva can name some pictures of animals on the flash cards, but is that going to help him tell stories about growing up in Guatemala? Mrs. Brown can follow complex directions and complete some worksheets, but is that going to help her cook her favorite recipes at home after recuperating from her hip fracture? Mrs. Robinson enjoys filling in the blanks in the cognitive workbook, but she’s still sitting by the nurse’s station every afternoon, constantly asking when her husband is arriving to take her home.
Many of us undoubtedly have had this feeling. But it doesn’t have to be this way: Put away the generic workbooks, picture flash cards and board games, and help your clients take part in activities that are important to them.
In this life-participation approach to care (see sources), rather than focusing on rote exercises the goal is to help clients achieve goals that are meaningful to them: cooking for their family, telling grandchildren about growing up in another country, or re-engaging in household chores and hobbies.

Many of us may often have left working thinking, “Did I really make a difference in the lives of my clients today?”

Person-centered care
The key to a life-participation approach is person-centered assessment and intervention, which “flips the rehab model,” as described by Michelle Bourgeois (see sources). Instead of clinician-directed assessment and treatment planning—testing the person to identify impairments, then using drills to improve the impairment—person-centered care is client-directed: Collaboratively written goals address the client’s and family members’ concerns, and aim to increase the person’s participation in meaningful life activities.
The approach weaves counseling and support into the intervention process to address the emotional impact of the diagnosis and resulting symptoms on the person with dementia and family members. Sounds great, but … you’re probably thinking, “There is no way I can personalize my treatment plan and materials for every person with dementia on my caseload. And it’s so hard to get family members involved. I don’t have enough time!”
Many barriers can make it difficult to implement an interdisciplinary, personalized approach to dementia care. Below are some practical tips and suggestions to help surmount such barriers.
Step 1: Person-centered assessment
Add a section to your assessment protocol. If you are using an electronic health record system that doesn’t permit personalization, add three itemized lists to your first treatment note:
  • Client concerns.

  • Family member concerns.

  • What is the impact of the impairments on participation? What activities are affected?

Step 2: Options
Many strategies can be used to support life-participation goals for people with dementia. Rather than focusing on the client’s type of dementia or trying to “stage” the client, focus on applying one or more evidence-based strategies to address the client’s and family members’ specific concerns (see sources).
For amnestic symptoms (memory loss), options include:
  • Visual and graphic cueing aids

  • Spaced retrieval training

  • Vanishing cues

  • Errorless learning

  • Simulated presence treatment

  • Environmental modifications and adaptations

  • Montessori interventions

  • Counseling

For aphasic symptoms (difficulties with lexical retrieval, apraxia, auditory comprehension), treatment could include:
  • Cueing hierarchies for lexical retrieval

  • Script practice

  • Personalized visual communication aids

  • Supported Conversation for Adults with Aphasia (SCA)

  • Counseling

Step 3: Apply the evidence-based strategies
Now that you know the client’s and family’s concerns, and you have a toolbox of treatment strategies, use those strategies to support the concerns, increase engagement in meaningful activities, and overcome perceived barriers.

Put away the generic workbooks, picture flashcards and board games, and help your clients take part in activities that are important to them.

What does this approach look like?
Here are three case examples of how to implement the life-participation approach to care.
Case 1: Mr. Silva—primary progressive aphasia
Client concern. Mr. Silva, whose primary symptom is aphasia, wants to be able to tell stories about his childhood in Guatemala.
Treatment. Strategies could include:
  • Personalized flash cards to target the lexical retrieval of words related to his childhood.

  • Script training for telling stories.

  • Communication wallet with important words and scripts printed on small cards.

Perceived barriers. If you perceive productivity requirements as a barrier to these strategies—“I don’t have time to create personalized visual aids”—you can create the content for the aids during treatment sessions with the client. Print and laminate them in the rehab office before the treatment session and then provide cues for the client to cut and organize the communication aids during the session as a therapeutic task. Involving the client in the process may also increase buy-in for use of the communication aids. Helpful apps include PowerPoint for portable wallet aids (each slide is a page of the wallet) and the PicCollage app for larger picture aids.
Treatment could also include:
  • Training Mr. Silva’s communication partners in supportive conversation strategies and how to cue the use of the communication aids.

  • Providing Mr. Silva and his family with disease education and support regarding his diagnosis.

  • Referring Mr. Silva and his family to a social worker who has experience with dementia care.

Perceived barriers. It’s difficult to actively involve family members in treatment sessions, because they are not there at those times. Some work-arounds include encouraging family members to attend treatment sessions, including the family member through conference calls or video chat, and leaving written notes with session recommendations in the client’s home or at the nurse’s station.
Case 2: Mrs. Brown—mild cognitive impairment
Client concern. Mrs. Brown, whose primary symptom is memory loss, wants to be able to cook her favorite recipes when she goes back home after her hip fracture.
Treatment. Helpful strategies may include:
  • Use of visual and graphic cueing aids to increase sequencing and recall for meal planning and preparation. These include modifying existing recipe cards by breaking the recipe into simple steps, adding pictures and using a large font; laminating a grocery list template of all the items she typically buys each week; and creating a menu planner template as a visual aid to plan each night’s meal.

  • Using photos Mrs. Brown brings from home, recommend how she might reorganize her pantry and refrigerator.

Perceived barriers. Perhaps you don’t have access to technology with which to create personalized aids during treatment. Try submitting a “wish list” to your rehab director that includes a smart tablet ($400), color printer ($50) and laminating machine ($30). Request these items over expensive, impairment-based standardized tests and workbooks, and present research that demonstrates the benefit of creating personalized stimuli for your clients.
Case 3: Mrs. Robinson—Alzheimer’s dementia
Client concern. Mrs. Robinson, whose primary symptom is memory loss, wants to go home with her husband. She sits at the nurse’s station asking repetitive questions about going home.
Treatment. Helpful strategies may include:
  • Visual and graphic cueing systems, such as a memory wallet displaying important information and answers to repetitive questions.

  • Spaced retrieval training to increase Mrs. Robinson’s use of the wallet.

  • Montessori approaches and visual aids to increase her engagement in meaningful activities, including stations to fold laundry, sweep with a broom and dustpan, and stuff envelopes.

  • Simulated-presence treatment with prerecorded videos of her husband on the facility smart tablet. He offers words of comfort and redirects her to the Montessori engagement stations.

  • Electronic memory books of family pictures and audio captions narrated by her husband, created using the Story Creator app.

Perceived barriers. Constant staff shortages and turnover make it difficult to educate the nursing staff about each client’s individual strategies. To help keep staff informed, provide monthly in-services. You could also develop “cognitive-communication recommendation forms” to be placed in patient-care binders indicating strategies and personalized intervention. When you speak with staff members, let them know you truly value their input and that you recognize they know the clients best. Respect their time—ask if they can give a few minutes or if they would prefer you chat with them as they perform routine duties.
Learn More at ASHA Connect

Becky Khayum will talk more about the life-participation approach to dementia treatment at ASHA Health Care Connect, July 20–22 at the Baltimore Convention Center.

This conference features more than two dozen sessions related to adult clinical issues, pediatric clinical issues and dysphasia. The lineup of experienced presenters will share relevant, practical tools that attendees can take home and implement immediately.

Khayum’s “Toss the Workbooks” session will include a presentation followed by a hands-on sessions in which participants can practice the skills they learn.

Health Care Connect is co-located with Schools Connect and Private Practice Connect—registrants are free to attend sessions from any of the conferences.

For more information and conference registration and housing (open April 9), visit www.asha.org/events/connect.

Beeson, P. M., King, R. M., Bonakdarpour, B., Henry, M. L., Cho, H., & Rapcsak, S. Z. (2011). Positive effects of language treatment for the logopenic variant of primary progressive aphasia. Journal of Molecular Neuroscience, 45(3),724–736. [Article] [PubMed]
Beeson, P. M., King, R. M., Bonakdarpour, B., Henry, M. L., Cho, H., & Rapcsak, S. Z. (2011). Positive effects of language treatment for the logopenic variant of primary progressive aphasia. Journal of Molecular Neuroscience, 45(3),724–736. [Article] [PubMed]×
Brush, J., Calkins, M., Bruce, C., & Sanford, J. (2013). Environment and communication assessment toolkit for dementia care (ECAT for dementia care). Health Professions Press.
Brush, J., Calkins, M., Bruce, C., & Sanford, J. (2013). Environment and communication assessment toolkit for dementia care (ECAT for dementia care). Health Professions Press.×
Bourgeois, M. (1990). Enhancing conversation skills in Alzheimer’s disease using a prosthetic memory aid. Journal of Applied Behavior Analysis, 23, 29–42. [Article] [PubMed]
Bourgeois, M. (1990). Enhancing conversation skills in Alzheimer’s disease using a prosthetic memory aid. Journal of Applied Behavior Analysis, 23, 29–42. [Article] [PubMed]×
Bourgeois, M., Burgio, L., Schulz, R., Beach, S., & Palmer, B. (1997). Modifying repetitive verbalization of community dwelling patients with AD. The Gerontologist, 37, 30–39. [Article] [PubMed]
Bourgeois, M., Burgio, L., Schulz, R., Beach, S., & Palmer, B. (1997). Modifying repetitive verbalization of community dwelling patients with AD. The Gerontologist, 37, 30–39. [Article] [PubMed]×
Bourgeois, M., Brush, J., Douglas, N., Khayum, R., & Rogalski, E. (2016). Will you still need me when I’m 64, or 84, or 104? The importance of speech-language pathologists in promoting the quality of life of aging adults in the United States into the future. Seminars in Speech and Language, 37,185–200. [Article] [PubMed]
Bourgeois, M., Brush, J., Douglas, N., Khayum, R., & Rogalski, E. (2016). Will you still need me when I’m 64, or 84, or 104? The importance of speech-language pathologists in promoting the quality of life of aging adults in the United States into the future. Seminars in Speech and Language, 37,185–200. [Article] [PubMed]×
Bourgeois, M.S., Brush, J., Elliot, G., & Kelly, A. (2015). Join the revolution: How Montessori for aging and dementia can change long-term care culture. Seminars in Speech and Language, 36, 209–214. [Article] [PubMed]
Bourgeois, M.S., Brush, J., Elliot, G., & Kelly, A. (2015). Join the revolution: How Montessori for aging and dementia can change long-term care culture. Seminars in Speech and Language, 36, 209–214. [Article] [PubMed]×
Camp, C., & Stevens, A. (1990). Spaced-retrieval: A memory intervention for dementia of the Alzheimer’s type. Journal of Aging and Mental Health, 10, 58–61.
Camp, C., & Stevens, A. (1990). Spaced-retrieval: A memory intervention for dementia of the Alzheimer’s type. Journal of Aging and Mental Health, 10, 58–61.×
Clare, L., & Jones, R. S. P. (2008). Errorless learning in the rehabilitation of memory impairment: A critical review. Neuropsychology Review, 18, 1–23. [Article] [PubMed]
Clare, L., & Jones, R. S. P. (2008). Errorless learning in the rehabilitation of memory impairment: A critical review. Neuropsychology Review, 18, 1–23. [Article] [PubMed]×
Croot, K., Nickels, L., Laurence, F., & Manning, M. (2009). Impairment- and activity/participation-directed interventions in progressive language impairment: Clinical and theoretical issues. Aphasiology, 23, 125–160. [Article]
Croot, K., Nickels, L., Laurence, F., & Manning, M. (2009). Impairment- and activity/participation-directed interventions in progressive language impairment: Clinical and theoretical issues. Aphasiology, 23, 125–160. [Article] ×
Eadie, T. L., Yorkston, K. M., Klasner, E. R., Dudgeon, B. J., Deitz, J. C., Baylor C.R., … Amtmann, D. (2006). Measuring communicative participation: A review of self-report instruments in speech-language pathology. American Journal of Speech-Language Pathology, 15, 307–320. [Article] [PubMed]
Eadie, T. L., Yorkston, K. M., Klasner, E. R., Dudgeon, B. J., Deitz, J. C., Baylor C.R., … Amtmann, D. (2006). Measuring communicative participation: A review of self-report instruments in speech-language pathology. American Journal of Speech-Language Pathology, 15, 307–320. [Article] [PubMed]×
Fried-Oken, M., Rowland, C., & Gibbons, C. (2010). Providing augmentative and alternative communication treatment to persons with progressive nonfluent aphasia. Perspectives on Neurophysiology and Neurogenic Speech and Language Disorders, 20, 21–25. [Article]
Fried-Oken, M., Rowland, C., & Gibbons, C. (2010). Providing augmentative and alternative communication treatment to persons with progressive nonfluent aphasia. Perspectives on Neurophysiology and Neurogenic Speech and Language Disorders, 20, 21–25. [Article] ×
Farrajota, L., Maruta, C., Maroco, J., Martins, I. P., Guerreiro, M., & de Mendonça, A. (2012). Speech therapy in primary progressive aphasia. Dementia and Geriatric Cognitive Disorders EXTRA, 2, 321–331. [Article] [PubMed]
Farrajota, L., Maruta, C., Maroco, J., Martins, I. P., Guerreiro, M., & de Mendonça, A. (2012). Speech therapy in primary progressive aphasia. Dementia and Geriatric Cognitive Disorders EXTRA, 2, 321–331. [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, 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, 126–145. [Article] [PubMed]×
Holland, A. (2007). Counseling in Communication Disorders: A Wellness Perspective. San Diego, CA: Plural Publishing.
Holland, A. (2007). Counseling in Communication Disorders: A Wellness Perspective. San Diego, CA: Plural Publishing.×
Jokel, R., & Anderson, N. D. (2012). Quest for the best: Effects of errorless and active encoding on word re-learning in semantic dementia. Neuropsychological Rehabilitation, 22, 187–214. [Article] [PubMed]
Jokel, R., & Anderson, N. D. (2012). Quest for the best: Effects of errorless and active encoding on word re-learning in semantic dementia. Neuropsychological Rehabilitation, 22, 187–214. [Article] [PubMed]×
Kagan, A., Black, S., Duchan, J., Simmons-Mackie, N., & Square, P. (2001). Training volunteers as conversation partners using “supported conversation for adults with aphasia” (SCA): A controlled trial. Journal of Speech, Language, and Hearing Research, 44, 624–638. [Article]
Kagan, A., Black, S., Duchan, J., Simmons-Mackie, N., & Square, P. (2001). Training volunteers as conversation partners using “supported conversation for adults with aphasia” (SCA): A controlled trial. Journal of Speech, Language, and Hearing Research, 44, 624–638. [Article] ×
Kagan, A., Simmons-Mackie, N., Rowland, A., Huijbregts, M., Shumway, E., McEwen, S., … Sharp S. (2008). Counting what counts: A framework for capturing real-life outcomes of aphasia intervention. Aphasiology, 258–280.
Kagan, A., Simmons-Mackie, N., Rowland, A., Huijbregts, M., Shumway, E., McEwen, S., … Sharp S. (2008). Counting what counts: A framework for capturing real-life outcomes of aphasia intervention. Aphasiology, 258–280.×
Murray, L. L., & Paek, E. J. (2016). Behavioral/nonpharmacological approaches to addressing cognitive-linguistic symptoms in individuals with dementia. Perspectives of the ASHA Special Interest Groups, 1, 12–25. [Article]
Murray, L. L., & Paek, E. J. (2016). Behavioral/nonpharmacological approaches to addressing cognitive-linguistic symptoms in individuals with dementia. Perspectives of the ASHA Special Interest Groups, 1, 12–25. [Article] ×
Simmons-Mackie, N., & Damico, J. (2001). Intervention outcomes: A clinical application of qualitative methods. Topics in Language Disorders, 22, 21–36. [Article]
Simmons-Mackie, N., & Damico, J. (2001). Intervention outcomes: A clinical application of qualitative methods. Topics in Language Disorders, 22, 21–36. [Article] ×
Sohlberg, M. M., Ehlhardt, L., & Kennedy, M. (2005). Instructional techniques in cognitive rehabilitation: A preliminary report. Seminars in Speech and Language, 26, 268–279. [Article] [PubMed]
Sohlberg, M. M., Ehlhardt, L., & Kennedy, M. (2005). Instructional techniques in cognitive rehabilitation: A preliminary report. Seminars in Speech and Language, 26, 268–279. [Article] [PubMed]×
World Health Organization. (2001). ICF: International classification of functioning, disability and health. Geneva: World Health Organization.
World Health Organization. (2001). ICF: International classification of functioning, disability and health. Geneva: World Health Organization.×
Youmans, G., Holland, A., Muñoz, M., & Bourgeois, M. (2005). Script training and automaticity in two individuals with aphasia. Aphasiology, 19, 435–450. [Article]
Youmans, G., Holland, A., Muñoz, M., & Bourgeois, M. (2005). Script training and automaticity in two individuals with aphasia. Aphasiology, 19, 435–450. [Article] ×
Zetteler, J. (2008). Effectiveness of simulated presence therapy for individuals with dementia: A systematic review and meta-analysis. Aging & Mental Health, 12(6), 779–785. [Article] [PubMed]
Zetteler, J. (2008). Effectiveness of simulated presence therapy for individuals with dementia: A systematic review and meta-analysis. Aging & Mental Health, 12(6), 779–785. [Article] [PubMed]×
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FROM THIS ISSUE
April 2018
Volume 23, Issue 4