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Evidenced Based Intervention for Neurodegenerative Disorders
Amanda Stead PhD., CCC-SLPPacific University
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What are Neurodegenerative Conditions?
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Spaced-Retrieval
Restorative / New Learning
Interventions
Adaptation / Compensation
Vanishing Cues
Montessori
Reminiscent
Caregiver Training:● Formal - FOCUSED● Teach Back Methods
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Montessori
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What is Montessori?
● Montessori is both a method and an environment
● Originally developed as an Educational Method
● The Montessori Method places an emphasis on independence, freedom within limits, and respect for a person’s natural psychological, physical, and social development.
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Rules of Montessori?
● You cannot give to the mind what you cannot give to the hands
● Beginning → Middle → End
● Preferred Activities that Play to Strengths and potetntial
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Why Use in in Elder Care?
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Change in participation or abilities
Decreased Opportunities
Change in routine, change in need, change in opportunity
Entry or Change in Care Locale
Increasing Need, increasing behavior, increasing disengagement
Decreased participation
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What Can Montessori do?
To Increase...
● Engagement● Socialization● Communication● Sense of Purpose● Sense of
Community
To Decrease...
● Anxiety● Agitation● Wandering● Depression● Isolation● Boredom
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Montessori Based Treatments
● Candidacy○ Episodic memory impairment but intact motor learning,
some verbal, socializing, no Hx of aggression○ Mild-mod and capable of attending intervention session○ Intact Sensory skills to complete activities
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MontessoriActivities that are Real Tasks
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Things We Always Did
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Things We Always Did
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Productive Completable Tasks
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Productive Completable Tasks
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Productive Completable Tasks
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MontessoriJob Assignments
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Jobs = Purpose
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Jobs = Purpose
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Jobs = Purpose
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MontessoriGames, Puzzles, & Crafts
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Complete Me
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Complete Me
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MontessoriSensorial Only
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Experience
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Experience
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Experience
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MontessoriCurating the Environment
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Montessori Areas
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Montessori Areas
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Montessori Areas
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Montessori Areas
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Montessori How To
● Slow down your movements - Match your speed to the person
● LET GO of idea that an activity activity has to be done the “right” way
● Goal is engagement & stimulation
● Encourage reminiscence
● Activities should be an error‐free source of success for people
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Montessori How To● Begin with an Invitation
● Consider sensory impairments
● Investigate motor control capabilities
● Observe potential to socialize with other residents or participate in group activities
● Practice with materials - demonstrate
● Choose tasks relevant to everyday life or preferred
● Choose a task someone can be successful with
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Montessori Materials
● Consist of materials that are aesthetically pleasing and are taken from the everyday environment
● Use external cues/templates
● Consist of materials are free of unimportant letters, numbers, words, or markings
● Be placed in a single container or on a single tray
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Conclusions● People have the need to feel successful.
● Being happily engaged in a satisfying activity reduces agitation, anxiety, depression, and anger.
● It may even reduce challenging behaviors like sundowning or reduce the need for medication.
● The inclusion of more montessori materials and activities can increase Quality of Life for Older Adults
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Montessori Based Treatments
● Outcomes:
○ Enhanced engagement and participation
○ Improved ability to independently preform task
○ Improved participation in Groups
○ **No change in cog status or impairment level testing
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What Can This Look Like?
https://www.youtube.com/watch?v=9Y6LCpL8HUU
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Reminiscent Therapies
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Reminiscence Therapy
● When patient are presented with materials relevant to their memories or life, it stimulate recall
● Use materials that trigger all senses● Personal relevance encodes stronger engrams● Good Themes for Reminiscence
○ Holidays○ Personal Milestones○ Weather events○ World events
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Reminiscence Therapy
● Candidacy:
○ Episodic memory impairment but able to engage with some verbal language
○ Mild-mod dementia and ability to tolerate social interaction
○ Functional vision and hearing for your task
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Reminiscence Therapy
● Steps for a good reminiscence session○ Select a relevant theme○ Develop Questions and probes to stimulate discussion○ Obtain relevant tangibles
■ Pictures■ Video clips■ Newspaper articles■ Clothes■ Props
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Reminiscence Therapy
● Ways to start a session:
○ “I found ____________”
○ “I wonder ___________”
○ “This feels, smells, sounds like ________”
○ “This reminds me of _______________”
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Reminiscent Boxes
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Reminiscent Books
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Reminiscent Engagement
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“Memory Book” 101
● Why do we use these?
● What are they for?
● What does the evidence say?
● What are the real applications and barriers?
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Reminiscence Therapy
● Expected Outcomes○ Small improvements on cog tests for some people
○ Greater number of conversational contributions
○ Improved discourse○ Increased recall of information related to topic
○ Best if used■ socialization goals■ Communication goals■ “Access”
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What Can This look like
https://www.youtube.com/watch?v=DAlrkb2XIe4
https://www.youtube.com/watch?v=5JjCwoJLoXM
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Conclusions
● Both Montessori and Remnicent methods are evidenced based approaches to working with dementia patients and those with lower cognitive function.
● Goals should be related to increased communication, decrease behaviors, increased engagement or priming
● These are just two of the MANY evidenced based approaches for patients with degenerative conditions
● Try it out!
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Spaced Retrieval
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Spaced Retrieval Training
● Recalling information over increasingly longer periods of time
● Easily seated in all activities
● Clinician varies targets and durations, when incorrect response received then previous duration in used again
● Varying degrees of long term carry over
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Spaced Retrieval Training
● Developed in 1978, but not used in dementia until 1985
● Possible success because of relatively spared nondeclarative memory-even though cannot remember the event of learning, information is retained
● In order for retention, information must be frequently used to reinforce learning
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Spaced Retrieval Training
• This approach may be used to help a person transfer movement (put a wallet in pocket after paying for something), follow a series of steps (put dishes in dishwasher after eating), or complete a task (say goodbye when someone leaves).
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SR Screen● The SR screen evaluates client’s ability to correctly recall
a target name for a person in a photograph over 3 different time intervals or Steps (Step 1 - immediately after presentation; Step 2 - after a 10 second interval; and Step 3 - after a 15 to 20 second interval).
○ At each Step the client is offered three trials.
○ Three trials per step.
○ Only advance to next step if successful at previous step.
○ Exit if not successful at Trial 3 of Step 1 or Step 2.
○ Consider offering the client a visual cue.
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SR Screen
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SR Goal Examples
● Disorientation - **Can we offer a better solution here?○ “Where do you live?” (Answer: Name of Facility)
○ “What is your room number?” (Answer: Room #)
○ “What is your address?” (Answer: Client’s address)
**What about a procedure???
● Repetitive Questioning○ Dependent upon question being asked
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SR Prompt Examples
● Naming○ “If you don’t know the name of something, what should you do?”
(Answer: “Describe It”)○ What is your husband/wife/son’s name? (Answer: Target name)○ Who runs the activities here? (Answer: Staff member’s name)
● Disengagement○ What can you read to remind you of your family? (Answer:
“Read my reminiscent book”)○ What can you check to see what is planned for the day?
(Answer: “Activity Schedule”)○ What can you look at to find something to do? (Answer: “My list
of activities”)
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SR & Documentation
● Measurement of goal attainment can be by percentage (“80% of time”) or by recalling and demonstrating target response for a set number of sessions (3 sessions recommended) depending on the type of goal.
○ “Client will recall strategy of inhaling prior to speaking in order to demonstrate appropriate vocal volume during 80% of structured sentence production”
OR○ “Client will demonstrate strategy of locking wheel chair
brakes prior to standing to increase safety at the beginning of 3 consecutive therapy sessions”
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SR & Documentation
● SR is considered to be a MODALITY or APPROACH that therapists may use to help clients reach their goals.
● SR does not fit one particular diagnosis category
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How This Can Look
https://www.youtube.com/watch?v=FiLzX1r8RVI
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Vanishing Cues
• Gradually reducing that amount of cuing that is used for the same information
• Begin with full name of an item and gradually reduce amount given for a cue in subsequent trials– Ex. For street name
• Foster• Fos__• Fo___• F____• ____
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Written and Graphic Cues
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Graphic and Written Cues● Graphic & Written Cues
○ Provide written information and photos to support recognition memory
■ use a memory wallet, ■ book, or ■ daily log■ Life history book: https://www.youtube.com/watch?v=5JjCwoJLoXM
(Hoerster, Hickey, & Bourgeois, 2001)
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Graphic & Written Cues
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Graphic and Written Cues
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Graphic and Written Cues
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Graphic and Written Cues
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Graphic and Written Cues
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FOCUSED Caregiver Training
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Focused Caregiver Training Program (Ripich & Ziol, 1999)
● Acronym for FOCUSED is: ○ F= face-to-face communication; ○ O= orient to topic; ○ C= continue with concrete topics; ○ U= resolve any communication blocks;○ S= structure with yes/no and choice questions; ○ E= encourage exchange conversation; ○ D= use direct, simple, short sentences.
http://www.ancds.org/assets/docs/EBP/educating_caregivers.pdf
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Teachback Method
Demonstrate the method - preferably with the patient
Model
Explain the topic, idea, or method you wish them to implement
Explain
Have Care partner implement and report back if possible
Understanding & Use
Have care partner practice, model and then provide feedback or clarification
Teachback
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CASE Studies● Yolanda - 3:00 -
https://www.youtube.com/watch?v=6r23xxh_U8s&list=PLXcdcIwcfUL1a42oj16bOzygw9hPGz8rU&index=10
● Woody - 7:30 - https://www.youtube.com/watch?v=L_AZRiL-1BY&list=PLXcdcIwcfUL1a42oj16bOzygw9hPGz8rU&index=11
● Marvine - 1:36 - https://www.youtube.com/watch?v=nj-Xko7U5ZQ&list=PLXcdcIwcfUL1a42oj16bOzygw9hPGz8rU&index=4
● Nacho - 4:50 - https://www.youtube.com/watch?v=jmV9QXMWOPE&list=PLXcdcIwcfUL1a42oj16bOzygw9hPGz8rU&index=3