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BEHAVIORAL TREATMENTS FOR DEMENTIA/MAJOR NEUROCOGNITIVE DISORDER: AN EVIDENCE-BASED UPDATE LAURA MURRAY, PH.D., CCC-SLP

Indiana University

Need for Speech-Language Pathology (SLP) Services

u  SLP scope of practice ¤ Extends beyond dysphagia ¤ Assessment and treatment of:

u Communication disorders n  Motor speech and voice n  Language n  **Communication problems contribute to both problematic behavior

and caregiver burden (Watson et al., 2012)

u Cognitive disorders n  Memory n  Attention n  Executive functions

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Examples of Cognitive-Communicative Profiles in Dementing Diseases

u  Alzheimer’s disease ¤ Early/primary deficit areas (Murray, 2010; Taler & Phillips, 2008; Scheltens

et al., 2015)

u Vascular dementia ¤ Language profile dependent on lesion locations (Calabro et al.,

2015; Wetzel & Kramer, 2008)

u Subcortical dementing diseases ¤ e.g., Parkinson’s disease (Murray, 2008; Murray & Rutledge, 2014)

u Syntax and reading comprehension problems u Decreased informativeness

¤ e.g., Huntington’s disease (Murray & Lenz, 2001; Murray & Stout, 1999)

Examples of Cognitive-Communicative Profiles in Dementing Diseases

u  Frontotemporal lobar degeneration (Anand et al., 2009; Chare et al., 2014; Harciarek et al., 2014)

¤ Dysexecutive/social disorder ¤ Semantic dementia (SD) or semantic variant progressive

aphasia ¤ Progressive nonfluent/agrammatic aphasia (nfv-PPA) ¤ Logopenic variant primary progressive aphasia (lv-PPA) ¤ Corticobasal syndrome

u Early/primary deficit areas n  Limb apraxia n  Visuospatial processing and visuoconstruction deficits n  Executive dysfunction

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Mild Cognitive Impairment (MCI)

u  MCI criteria (Faucounau et al., 2010; Ries et al., 2007)

¤ Does not fulfill DSM-IV dementia criteria ¤ Cognitive problems ¤  Preserved ADLs and nominal problems with IADLs

u  MCI statistics (Alzheimer’s Association, 2014)

¤  10-20% of individuals ≥ 65 yr ¤ About 15% of those with MCI convert to AD each year (vs. 1-2%

conversion rate in healthy adults) ¤ About 50% who visit doctor regarding MCI symptoms convert to

dementia diagnosis in 3-4 years

u  Highly variable cognitive profiles (Aretouli & Brandt, 2010; Krueger et al., 2011; Libon et al., 2010; Reinvang et al., 2012; Springate & Tremont, 2012)

Dementia Protective Factors Include (Bennett et al., 2014; Kempler & Goral, 2008; Lopez, 2011):

u  Early diagnosis and treatment of vascular disorders u  Establishing and maintaining a rich social network

u  Keeping intellectually and physically active

u  Therefore, cognitive-communicative behavioral treatment approaches should help slow rate of decline!

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Therapeutic Nihilism

u  Case example u  Some depressing statistics

¤ Mean of 65 min/day of skilled therapy (combined across disciplines) for patients with sub-acute conditions

u  However: ¤ Centers for Medicare and Medicaid Services (2001):

u “Through the course of their disease, patients with dementia may benefit from pharmacologic, physical, occupational, speech-language, and other therapies.”

¤ Nonpharmacologic treatments are part of guideline recommendations u National and international professional and government organizations (e.g.,

American Psychiatric Association, American Academy of Neurology, NIH and Clinical Excellence, United Kingdom Dept. of Health) (Geldmacher & Kerwin, 2013; Giebel & Challis, 2014; NICE, 2006)

Barriers (Geldmacher & Kerwin, 2013)

u  Primary care physicians in US report barriers regarding their role in managing dementia cases such as: ¤ Lack of time ¤ Negative perception with respect to importance of

early diagnosis ¤ Difficulty managing behavior and other problems in

dementia ¤ Lack of connections with community service agencies

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Memory Strategies

u  Internal Memory Strategies ¤ e.g., visual imagery, association, alphabet cueing ¤ Useful for MCI patients only, particularly if (Hampstead et al., 2008;

Stott & Spector, 2010): u Sufficiently long training u Focus training on only 1 strategy u Train strategy specific to type of info they are trying to retain

Memory Strategies

u  Low and high tech external memory strategies ¤ Specific vs. variety of settings ¤ Useful for broader dementia population

u  Outcomes: u  Patients with MCI benefit from external memory strategies (Bourgeois,

2013; Giebel & Challis, 2014; Hampstead et al., 2008; Stott & Spector, 2011)

u  Mild-moderate dementia patients benefit from external strategies (De Leo et al., 2011; Imbeault et al., 2014; Nugent et al., 2011; Schmitter-Edgecombe et al., 2008; Yasuda et al., 2009, 2013) n  Most research on memory books and smart phones

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Memory Strategies

u Must explicitly train external device and strategy use (Mateer, 2009; Singer & Bashir, 1999; Sohlberg et al., 2007; Murray & Clark, 2015)

¤ Requires systematic instruction u Acquisition

n  how to use strategy n  often taught via errorless learning

u Application n what strategy can do

u Adaptation n when, where, and with whom to use

Memory Strategies

u  Factors influencing device/strategy use (DePompei et al., 2008; O’Connell et al., 2003) ¤ Patient motivation ¤ Sensory and motor issues

u e.g., visual or auditory impairments u e.g., intention tremor or paresis

¤ Familiarity with technology ¤ Selection of features to motivate ¤ Support for programming and troubleshooting

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Intensive/Cognitive-Linguistic Stimulation

u Across studies (Bourgeois, 2013; Chapman et al., 2004; Ciancarelli et al., 2010; Ciro et al., 2014; Clare et al., 2010; Farina et al., 2006; Faucounau et al., 2010; Hoffman et al., 2015; Matsuda et al., 2010; Murray et al., 2015; Orrell et al., 2005; Sitzer et al., 2006; Spector et al., 2010; Tesar et al., 2005; Treiber et al., 2011; Viola et al., 2011; Yi-Xuan et al., 2010)

¤ Involved patients with mild to moderate dementia ¤ Included MCI, AD, FTD, VaD, MS, PD, mixed, and

unspecified ¤ Protocol variation examples

u Caregiver vs. healthcare professional u Individual vs. group sessions u Do vs. don’t include activities from other approaches u Target 1 vs. multiple cognitive-linguistic skills u Number, length, and frequency of sessions

Intensive/Cognitive-Linguistic Stimulation

u  Outcomes across studies (Chapman et al., 2004; Ciancarelli et al., 2010; Clare et al., 2010; Faucounau et al., 2010; Hindle et al., 2013; Hoffman et al., 2015; Matsuda et al., 2010; Murray et al., 2015; Orrell et al., 2005; Sitzer et al., 2006; Spector et al., 2003, 2010; Tesar et al., 2005)

¤ é attention, memory, executive function, language, ADL skills ¤ ê patient neuropsychiatric problems and caregiver depression

and distress ¤ é patient and caregiver QOL and perceptions of general

functioning ratings ¤ é brain activation ¤ > outcomes in cognitive-linguistic stimulation + donepezil vs.

donepezil alone (Chapman et al., 2004; Matsuda et al., 2010; Rozzini et al., 2007)

¤ Effects typically maintained 4.5 months post-tx (Sitzer et al., 2006)

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Montessori-Based Intervention

u  Principles of Montessori approach (Camp, 2010; Livingston et al., 2005; Mahendra et al., 2006)

¤ Take place in prepared environment ¤ Progress from simple/concrete to complex/abstract ¤ Break task/activity into its parts

u Train each part sequentially with cues to minimize errors and maximize success

¤ Progress from observation and recognition to recall and demonstration

¤ Use real-life materials and daily activities/contexts ¤ Emphasize all sensory modalities ¤ Work at one’s own pace

u  Individual or group sessions

Montessori-Based Intervention

u  Session number, length, and frequency have varied ¤ 25-60 min sessions; twice daily-twice weekly; 3-9 months

u  Example activities ¤ Memory Bingo ¤ Question Asking Reading on common topics ¤ Sensory activities ¤ Abstract activities ¤ ADLs and IADLs ¤  Intergenerational activities

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Montessori-Based Intervention

u  Variety of dementia types ranging from mild to severe ¤ AD, VaD, mixed

u  Outcomes across studies (Camp et al., 1997; Giroux et al., 2010; Gozali & Jarrott, 2002; Judge et al., 2000; Lee et al., 2007; Lin et al., 2010; Orsulic-Jeras et al., 2000; Pampano et al., 2001; Skrajner & Camp, 2007; van der Ploeg & O’Connor, 2010; van der Ploeg et al., 2013):

¤ é active/task engagement, positive affect/pleasure, functional status, social interaction, independent task completion

¤ ê passive/no engagement, negative affect, eating difficulty, repetitive vocalizations, apathy, confusion, aggression, agitation

Reminiscence Therapy

u  Rationale (Kim et al., 2006; Lazar et al., 2014; O’Shea et al., 2011; Wang, 2007)

¤ Retrograde memory may be less degraded ¤ Reminiscence involves all cognitive-linguistic domains

u  Used with: ¤ Various dementia types and severities

u  Procedures involve: ¤ Typically group format

u In person or telerehab

¤ Focus on one theme or topic per session ¤ Utilize props, pictures, objects, music, video clips and games to

trigger memory/discussion

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Reminiscence Therapy

u  e.g., StoryCorps (http://www.storycorps.org) ¤ National nonprofit organization that records and

preserves stories of everyday people (Ball, 2011) u Memory Loss Initiative

Reminiscence Therapy

u  Outcomes across studies (Akanuma et al., 2011; Chiang et al., 2010; Cotelli et al., 2012; Davis et al., 2012; Hsieh et al., 2010; Jo & Song, 2015; Lazar et al., 2014; Nawate et al., 2008; Shik et al., 2009; Su et al., 2013; Wang et al., 2009; Yamagami et al., 2007; Yasuda et al., 2009; 2013)

¤ ê depression, agitated behaviors, apathy, social isolation ¤ é in a variety of areas:

u arousal u cognitive skills including attention and immediate and delayed

recall u cingulate activation u overall well being u amount of verbal output u QoL/self-worth u social skills/friendships

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Implicit Memory Approaches

u  Implicit memory/learning (Bayles & Kim, 2003; Knowlton & Foerde, 2008)

¤ Nondeclarative memory/learning/recall that can be achieved without awareness or effort

¤  Includes priming, habitual/procedural memory ¤ Associated with caudate and other basal ganglia

structures and cerebellum ¤ Utilized with variety of dementia severities and types

Implicit Memory Approaches

u  Spaced retrieval (Balota et al., 2006; Bourgeois et al., 2003; Bourgeois & Melton, 2004; Brush & Camp, 1998; Cherry et al., 2010; Giebel & Challis, 2014; Hopper et al., 2004, 2010; Lee et al., 2009; Wu et al., 2014)

¤  Recall information over progressively longer intervals ¤  Target behaviors have included:

u important names (i.e., face-name associations) u use of compensatory techniques u motor transfer techniques u room number and location

¤ Appropriate for mild to severe dementia ¤  In person and phone intervention ¤ Outcomes across studies:

u é recall of target info or skill u No generalization

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Implicit Memory Approaches

u  Errorless learning (Avila et al., 2004; Clare, 2001; Clare & Jones, 2008; Dechamps et al., 2011; Dunn & Clare, 2007; Gonzalez Rothi et al., 2009; Jokel et al., 2010; Page et al., 2006; Wu et al., 2014)

¤ Cue or break down tasks into discrete steps so client never makes a recall error

¤  Target behaviors have included: u Face/name associations u Word list learning u ADLs (e.g., food prep; eating behaviors) u External strategy use

¤ Used with MCI and AD, FTLD, and VaD of various severities

Implicit Memory Approaches

u  Errorless learning outcomes across studies (Avila et al., 2004; Clare, 2001; Clare & Jones, 2008; Dechamps et al., 2011; Dunn & Clare, 2007; Gonzalez Rothi et al., 2009; Jokel et al., 2010; Page et al., 2006; Wu et al., 2014)

¤ é in trained skill/content only ¤ Outcomes may vary across patients ¤ Inconsistent findings regarding benefits of errorless vs.

errorful/effortful learning u > effortful learning (e.g., Dechamps et al., 2011; Jokel et al., 2010)

u Same as effortful learning (e.g., Dunn & Clare, 2007; Haslam et al., 2006)

¤ Often applied in concert with spaced retrieval (e.g., Lowenstein et al., 2004; Wu et al., 2014)

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Holistic/Alternative Approaches

u  Sensory stimulation approaches (Anderson et al., 2011; Bradt et al., 2010; Camberg et al., 1999; Chung & Lai, 2009; Fowler, 2008; Kverno et al., 2009; Livingston et al., 2005; Materne et al., 2014; Milev et al., 2008; Murray et al., 2003; Riley-Doucet, 2009; Yasuda et al., 2009)

u Rationale n Dementia patients suffer from sensory/perceptual deterioration due

to: u Normal aging effects u Disease effects u Sensory deprived environments

n  Sensory deprivation leads to: u Disruptive behaviors u General confusion u Cognitive decline u Psychiatric disorder

u Appropriate for all dementia severities u Session number and duration varied

Holistic/Alternative Approaches

u Sensory stimulation approaches (Anderson et al., 2011; Bradt et al., 2010; Chung & Lai, 2009; Fowler, 2008; Krishnamoorthy & Craufurd, 2011; Kverno et al., 2009; Livingston et al., 2005; Milev et al., 2008; Murray et al., 2003; Riley-Doucet, 2009; Yasuda et al., 2009)

u Types n pet therapy n toy stimulation n music therapy n light therapy n Snoezelen n simulated presence (Camberg et al., 1999; Cohen, 2000; Lund et al.,

1995; Yasuda et al., 2009)

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Holistic/Alternative Approaches

u Sensory stimulation approaches (Anderiesen et al., 2014; Anderson et al., 2011; Bradt et al., 2010; Chung & Lai, 2009; Fowler, 2008; Krishnamoorthy & Craufurd, 2011; Kverno et al., 2009; Livingston et al., 2005; Materne et al., 2014; Milev et al., 2008; Murray et al., 2003; Riley-Doucet, 2009; Yasuda et al., 2009)

u Outcomes across studies n é primarily while doing the activity

u é in a variety of areas: u ê disruptive behaviors, agitation, apathy

Holistic/Alternative Approaches

u  Movement/exercise therapy (Cott et al., 2002; de Carvalho Bastone & Filho, 2004; Hale et al., 2003; Hindle et al., 2013; Roach et al., 2011; Rogalski & Quintana, 2013; Steinberg et al., 2009; Toto et al., 2001; Yu et al., 2006) ¤ e.g., yoga, dance activities, walking, recumbent bike, ROM

and balance exercises, strength/weight training ¤ Often used in concert with cognitive training ¤ Used with variety of dementia types and

severities

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Holistic/Alternative Approaches

u  Movement/exercise therapy (Cott et al., 2002; de Carvalho Bastone & Filho, 2004; Hale et al., 2003; Harkawik & Coyle, 2012; Hindle et al., 2013; Roach et al., 2011; Rogalski & Quintana, 2013; Steinberg et al., 2009; Toto et al., 2001; Yu et al., 2006)

¤  Improvements or slower declines observed in: u Physical/cardiovascular functioning u Sleep patterns u Cognitive skills u Emotional well being u ADLs and transfers u Motor speech

Caregiver Training

u  Family is primary source of caregiving for dementia population (AA, 2014; Stefanacci et al., 2011)

u  Important component of contextualized rehabilitation (Sander et al., 2009)

¤ Contextualized = tx provided within patient’s daily context

u  Provide with educational and counseling resources ¤ Family Caregiver Alliance http://www.caregiver.org ¤ NIH/MedlinePlus

http://www.nlm.nih.gov/medlineplus/alzheimerscaregivers.html ¤ FTD Caregiver Support Center http://ftdsupport.com ¤ Harvard Health Publications; e.g.,

http://www.helpguide.org/elder/vascular_dementia.htm

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Caregiver Training

u  Must move beyond reading material only u  Assure they understand:

¤  rationale for treatment procedures/strategies ¤  importance of keeping time for themselves and thus, protecting

their own physical and mental health

u  Task demand modifications (Catroppa & Anderson, 2006; Kurz et al., 2012; Sohlberg & Mateer, 2001; Murray & Clark, 2015)

u  Social Manipulations (Murray & Clark, 2015)

¤ Aimed at minimizing learned helplessness ¤ Assure dementia patient has social role other that of “dementia

patient”

Caregiver Training

u  Environmental Accommodations (Anderiesen et al., 2014; Bruce et al., 2013; Brush et al., 2002; Brush & Calkins, 2008; Gitlin et al., 2010; Giovannetti et al., 2007; Livingston et al., 2005; Small et al., 2003; Topo, 2009)

¤  Fall within WHO ICF model and SLP scope of practice ¤ Keep environment predictable and distraction free ¤ Assure adequate visual contrast and lighting ¤ Personalization ¤ Safety accommodations ¤ Consider comfort ¤ Pacing strategies (Sohlberg & Mateer, 2001)

¤ Organizational systems (Michel & Mateer, 2006)

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Caregiver Training

u  Linguistic manipulations (Haberstroh et al., 2011; Petryk & Hopper, 2009; Small et al., 2003; Small & Perry, 2005, 2012; Watson et al., 2012; Wilson et al., 2012)

¤ Content u e.g., simplify vocabulary; repeat information; open-ended questions that

require responses from semantic memory; limit to one proposition/direction/idea; communicate about topics in the present/”here and now”

¤  Structure u e.g., short, simple utterances; one point at a time; cued or forced-choice

questions during ADLs; open-ended questions to encourage conversation ¤ Use

u e.g., identifying and extinguishing elderspeak, avoid indirect speech acts and figurative language; use alerting cues; speak face-to-face; within a conversation, limit number of partners and allow extra time for processing/responding; incorporate visual aids/contextual support

u Reduced speech rate may be detrimental u Educate on lack of sensitivity

Caregiver Training

u Can be trained to administer all direct intervention approaches just reviewed (e.g., Avila et al., 2004; O’Shea et al., 2011; Riley-Doucet, 2009; Steinberg et al., 2009)

u Training in person and/or telerehab

u  Caregiver training programs described and evaluated in the empirical literature. Examples include: ¤ Circle Model (Jansson et al., 1998) ¤ TANDEM model (Haberstroh et al., 2011)

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Caregiver Training

u Outcomes of across caregiver training studies (Done & Thomas, 2001; Gitlin et al., 2010; Haberstroh et al., 2011; Kuo et al., 2013; Livingston et al., 2005; Marriott et al., 2000; Small & Perry, 2012; Watson et al., 2012)

¤ ê distress, depression, communication problems between caregiver-patient pairs

¤ é emotional well being of caregiver and patient

¤ Delay institutionalization of patient ¤ é QoL in patients

Combined Approaches

u  Consistent positive outcomes among intervention programs that combine two or more of the previously reported approaches (Bourgeois, 2013; Pimental, 2009)

¤ e.g., external memory strategies + reminiscence tx + caregiver training (Kurz et al., 2012)

¤ e.g., reminiscence tx + art tx + music tx (Jo & Song, 2015)

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Matsuda, O., Shida, E., Hashikai, A., Shibuya, H., Kouno, M., Hara, C., & Saito, M. (2010). Short-term effect of combined rug therapy and cognitive stimulation therapy on the cognitive function of Alzheimer's disease. Psychogeriatrics, 10(4), 167-213.

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Scheltens, N. M., Galindo-Garre, F., et al. (2015). The identification of cognitive subtypes in Alzheimer's disease dementia using latent class analysis. Journal of Neurology, Neurosurgery & Psychiatry, jnnp-2014.

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