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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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