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“They’re just going to get worse anyway”: perspectives on rehabilitation for nursing home residents with dementia
Journal of Communication Disorders 36 (2003) 345–359
‘‘They’re just going to get worse anyway’’: perspectives on rehabilitation for nursing home residents with dementia Tammy L. Hopper* Department of Speech Pathology and Audiology, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, Alta., Canada T6G 2G4 Received 15 March 2003; received in revised form 15 May 2003; accepted 15 May 2003
Abstract In recent years, researchers have provided data to show that individuals with Alzheimer’s disease (AD) can learn new information and functional behaviors, despite significant declarative memory deficits. However, clinicians in long-term care frequently have difficulty justifying and providing needed services to persons with Alzheimer’s disease in LTC settings. In this paper, implicit learning will be discussed as a theoretical rationale to support rehabilitation along with practical issues related to the provision of speechlanguage pathology services for residents with Alzheimer’s disease in LTC settings. Learning outcomes: After reading this article, learners will be able to: (1) Define implicit learning; (2) discuss evidence for implicit learning in Alzheimer’s disease; (3) describe how to capitalize on implicit learning during rehabilitation for individuals with Alzheimer’s disease; (4) explain how to justify and provide interventions for individuals with Alzheimer’s disease in LTC settings. # 2003 Elsevier Inc. All rights reserved. Keywords: Implicit learning; Treatment; Alzheimer’s disease; Long-term care
Rehabilitation for dementia is plagued by misconceptions. Personal and professional caregivers of people with dementia often ask why they should support rehabilitation efforts when they know that the person with dementia is only ‘‘going to get worse’’ anyway. This situation is compounded by the fact that *
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0021-9924/$ – see front matter # 2003 Elsevier Inc. All rights reserved. doi:10.1016/S0021-9924(03)00050-9
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many health care professionals, including speech-language pathologists (SLPs) share this view. In a recent survey of speech-language pathologists in Canada, 44% of respondents did not agree that individuals with dementia could benefit from speech-language pathology interventions (Cleary, Donnelly, Elgan, & Hopper, 2003). In fact, many rehabilitation professionals, long-term care administrators, and third party payers have stated that the provision of cognitive interventions for dementia is unethical as individuals with dementia cannot be expected to benefit from such interventions. In recent years, however, researchers have provided evidence that individuals with Alzheimer disease (AD) and other types of dementia can benefit from structured behavioral treatments that reduce demands on impaired cognitive abilities and capitalize on spared ones. The benefits of these interventions are observed in outcomes such as more time actively engaged in their environment and improved affect (Judge, Camp, & Orsulic-Jeras, 2000; Orsulic-Jeras, Judge, & Camp, 2000), improved ability to recognize or recall proper names (Brush & Camp, 1998a; Hopper & Bond-Moore, 2003; Vanhalle, Van der Linden, Belleville, & Gilbert., 1998), improved ability to carry out specific tasks (McKitrick, Camp, & Black, 1992; Zanetti et al., 1997), and reduced occurrence of negative verbal behaviors such as repetitive question-asking (Brush & Camp, 1998b). Despite these positive outcomes, little has been written regarding mechanisms of learning in Alzheimer’s disease and how implicit learning, a preserved form of learning in AD, may be used to promote improved function and justify cognitivecommunicative interventions. In this paper, implicit learning in AD will be discussed, followed by a summary of the reality of implementing therapy programs in long-term care facilities. Finally, implications for future research and clinical efforts will be discussed.
1. Implicit learning in Alzheimer’s disease By definition, individuals with Alzheimer’s disease have deficits in memory and learning. However, not all aspects of memory and learning are equally affected. Whereas semantic memory and non-declarative memory systems may be relatively intact until late in the disease process, episodic and working memory are diminished even in the early stages. As a result, explicit learning is adversely affected. Explicit learning is described as acquisition of knowledge under conditions in which the individual intends to learn (Schacter, Rich, & Stampp, 1985). For example, explicit learning occurs when individuals study conceptual associations for an exam, perhaps using strategies such as visual imagery and chunking of information, knowing that they will be tested on their knowledge of the information at a later time. Explicit tests of learning are ones that employ recall or recognition tasks (Buchner & Wippich, 1998). For example, an exam may consist of free recall (e.g., essay) and recognition (e.g., multiple-choice) questions. These tests are considered explicit tests because correct responding requires conscious
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recollection of previously studied events (Buchner & Wippich, 1998). Explicit learning is a manifestation of episodic memory and is therefore also prominently impaired in AD. However, implicit learning may be more intact. Implicit learning refers to the acquisition of knowledge or skills that is incidental (Seger, 1998). That is, during the acquisition phase of an implicit learning task, individuals are not intending to learn new information or behaviors. Thus, ‘‘. . . encoding occurs without the subject’s intention to learn, and learning is measured by the influence of that knowledge on another task . . . rather than being tested with recall or recognition’’ (Stadler & Roediger, 1998, p. 108). For example, after exposure to pictures of ‘‘things people wear,’’ Arkin, Rose, and Hopper (2000) found that individuals with AD named many of the pictured items on a generative naming task whereas before exposure to the pictures they had named few if any of them. This result is an example of priming, whereby a later response is advantaged by presentation of an earlier related stimulus. Although some researchers have argued that priming is impaired in individuals with AD (Heindel et al., 1989), evidence from clinical research suggests that implicit learning may be relatively preserved in this population. Several authors have reported positive learning gains using spaced-retrieval training (SRT) or repeated exposure to a stimulus-response pairing over expanding intervals of time. (See Bourgeois et al., accepted this volume, for a detailed review.) Specifically, SRT has been used to teach individuals with mild to moderately severe dementia a variety of associations such as names (Vanhalle et al., 1998), procedures (Hopper & Bayles, 2001), and compensatory strategies (Brush & Camp, 1998a; Camp, Foss, O’Hanlon, & Stevens, 1996). Whereas the SRT procedure is thought to rely upon implicit learning, as many individuals exhibit knowledge of the learned associations without explicit recall of the learning situation, explicit tests of recognition and recall are frequently used to assess this knowledge. That is, patients are directly asked about the association learned (e.g., ‘‘What is this person’s name? What do you do when you need to find out when lunch is served?). Thus, the patient may be learning implicitly but this learning is assessed explicitly. In recent work using recall and recognition tests in SRT, several individuals with moderate AD who could not recall a trained association could recognize it when given a choice, demonstrating implicit knowledge of the learned information though free recall was impaired (Hopper & Bond-Moore, 2003). It is important to consider the effects of the test situation when documenting learning gains in AD, as acquisition of new behaviors and information may not be apparent if tested using explicit recall tests.
2. Implicit learning and errors Whereas individuals with intact episodic memory may ‘‘learn from their mistakes,’’ implicit learning may be hampered by errors. Baddeley and Wilson (1994) suggest that individuals with episodic memory impairment, as in AD and
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other dementias, have difficulty eliminating errors made during learning trials because they cannot explicitly recall the learning experience; thus they continue to make the same errors on subsequent trials. The susceptibility of individuals with AD to the effects of interference may result in decreased ability to inhibit the production of prior error responses. The errorless learning technique has been used successfully with amnesic patients (Baddeley & Wilson, 1994; Wilson, Baddeley, & Evans, 1994) using word stem completion tasks. Additionally, Wilson et al. (1994), Evans et al. (2000) and Clare, Wilson, Breen, and Hodges (1999) reported positive learning outcomes in a series of studies in which errorless learning was used to teach practically relevant knowledge and skills, including face–name associations. Taken together, the evidence for preservation of implicit learning in AD is compelling and provides a strong rationale for cognitive-communication interventions for individuals with dementia. However, actual clinical implementation of such interventions in long-term care (LTC) settings requires knowledge not only of theory and research evidence but of the nature of service delivery in LTC environments.
3. Providing SLP Services in the LTC environment According to Medicare regulations for LTC facilities, nursing home residents must receive, and the facility must provide, care and services to maintain their highest practicable mental, physical, and psychosocial well-being, in accordance with a comprehensive assessment and care plan (Health Care Financing Administration, 1991). This requirement ensures that residents receive necessary rehabilitation services for the stated purposes of optimal care and functioning. However, in the past some Medicare intermediaries automatically denied rehabilitation services based solely on the ICD-9 diagnostic codes for dementia. The Centers for Medicare and Medicaid Services no longer allow intermediaries to deny claims on the basis of dementia diagnosis alone (CMS Transmittal AB-01-135, 2001), yet many therapists are reluctant to provide services to this populations. In their previously mentioned survey of Canadian SLPs, Cleary et al. (2003) also found that 60% believed that individuals with dementia could benefit from SLP interventions, yet the demands of treating other patients prevented them from providing services to persons with AD. This situation is now common in skilled nursing facilities in the U.S. as well. As the medical complexity of the average patient in LTC facilities increases, the demand increases for rehabilitation professionals to provide care to people who are transferred directly from the hospital. Individuals with dementia will not typically have the acuity that requires immediate rehabilitation efforts, unless that person has been re-admitted to the nursing home after a hospital stay for orthopedic or neurological reasons. Lack of referrals was also noted in the reasons for limited service provision to people with dementia. Seventy-five percent of respondents in the Cleary et al.
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(2003) survey stated that they did not routinely receive referrals to assess or treat individuals with dementia. Education of staff in LTC facilities, as well as physicians and other therapists, will help to increase the profile of the SLP and will improve awareness of the nature of services that the SLP can provide to residents with dementia.
4. How to intervene: the functional maintenance program — alive and well In 1995, Glickstein and Neustadt (1995) published a primer on a Functional Maintenance Program (FMP) for use in skilled nursing facilities. Clinicians develop a FMP based on a comprehensive evaluation of functioning of the person with dementia and train caregivers in program implementation. Whereas the Health Care Financing Administration (HCFA) has implemented several changes to reimbursement for rehabilitation for individuals in long-term care (i.e., PPS, cost-capitation for Medicare B recipients), the FMP remains viable as a mechanism for short-term, consultative intervention for individuals with dementia. According to the HCFA, a FMP is indicated when (1) a resident demonstrates a documented change in condition; (2) has a medical condition associated with loss of function; (3) is being discharged from skilled therapy and requires a directed intervention to maintain outcomes achieved during rehabilitation; and (4) requires skilled intervention to up-date an established program. Although FMPs are the primary method by which individuals with dementia receive skilled rehabilitation services, the culture of the nursing home is a barrier to effective implementation of communication-focused FMPs. Specifically, in a consultative model like a FMP, SLPs must rely on staff to continue the intervention once the skilled assessment and design of the program are completed. Though SLPs should consistently monitor and re-assess residents at regular intervals, certified nurses’ aides (CNAs) or restorative nurses’ aides are left to ensure the program recommendations are followed for each resident. Given the high turnover of nursing support staff in traditional LTC facilities and the high ratio of residents to staff caregivers, the success of the FMP is not ensured unless SLPs rely upon other individuals to provide support for their interventions. Staff who manage Activities departments in many long-term care facilities are logical choices for continuing provision of FMPs related to communication and cognition. Many goals of the FMP can be nested within activity programs and the structure of these programs is conducive to naturally occurring conversation with other residents, staff, and volunteers.
5. When to intervene The best time to develop a FMP for a person with dementia is upon admission to the LTC facility or when a significant change in function occurs. The SLP
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should be involved in the screening of each new resident and can interview family caregivers regarding any change in functional abilities coincident with the relocation. A substantial literature on transfer trauma indicates that involuntary moves of older persons from one facility to another can have detrimental effects on functioning (e.g., Lawton, 1986; Pruchno & Rose, 2000; Selzer, Sun, & Gutman, 2001). As many admissions to LTC facilities are frequently precipitated by a medical change in status (e.g., hip fracture, pneumonia), therapists should expect ‘‘de-compensation’’ or a decline in ability to perform activities of daily living, including communication. Changes in functional status also occur at other times for many reasons, among them loss of a loved one, depression, illness, and progression of the dementia. In addition to nursing documentation of these changes in status, other professionals such as speech-language pathologists, physical and occupational therapists must officially note a significant change in condition. Thus, if a therapist notes a decline in a residents’ ability to communicate for basic needs and/or social purposes, other team members should also note the change in their chart notes. If a significant change in function is noted in two or more areas, then a re-evaluation using the Minimum Data Set (MDS; Morris et al., 1990) is required. The MDS is a comprehensive assessment measure mandated for use in all LTC facilities receiving Medicare payments. The measure is completed for each resident upon admission, quarterly and annually and includes sections on Communication and Hearing, Cognitive Patterns, and Functional Rehabilitation Potential, among others. Bayles and Tomoeda (1997) recommended that clinicians use the MDS when working with people with dementia in LTC settings to develop programs and goals. However, in many settings, SLPs are not involved in MDS evaluations (Cleary & Hopper, 2000) and the information obtained on communication and hearing patterns of residents with dementia may not be accurate (Hopper, Bayles, Harris, & Holland, 2001). Without involvement in this mandated assessment process, SLPs may fail to recognize that a resident’s status in communication has changed and thus fail to receive appropriate referrals. A change in functional status is necessary to justify SLP interventions; however, it is not sufficient. There must also be a reasonable expectation of improvement as a result of the proposed intervention. In the HCFA Manual, 230.3, section A 2, regulations for provision of speech therapy services require that there must be an ‘‘expectation that the [resident’s] condition will improve significantly in a reasonable (and generally predictable) period of time.’’ With regard to dementia, this point deserves special emphasis. In all settings, including LTC, there must be indicators of positive prognosis for achievements of rehabilitation goals. This positive prognosis is usually documented in the ‘‘Functional Rehabilitation Potential’’ section of the MDS for those residents in skilled nursing facilities. If this section does not contain information that would lead a payer to believe that the resident could benefit from interventions (i.e., ‘‘poor’’ rehabilitation potential is indicated), then the claim for reimbursement will be denied. The most convincing rationale for intervening with residents with dementia is based
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on two positive prognostic indicators (e.g., potential to learn, family support, prior level of function). It is incumbent upon therapists to identify and document areas of strength upon which to capitalize in therapy. This information will demonstrate that residents with dementia have the potential to benefit from the planned intervention. Additionally, SLPs must identify communication abilities that may be vulnerable in the future and develop plans for scheduled screening and re-evaluation of skills. The idea is to target vulnerable skills with the hopes of staving off precipitous declines in communication abilities. The Functional Linguistic Communication Inventory (FLCI; Bayles & Tomoeda, 1994) allows clinicians to profile communication strengths and weaknesses, as well as abilities that are susceptible to decline in the future. Clinicians should utilize this or some other well-designed profile of functioning such as the Severe Impairment Battery (SIB; Saxton, McGonigle, Swihart, & Boller, 1993) to help design therapeutic programs with the goal of optimizing communication for as long a period as possible. Though many clinicians balk at the administrative or fiscal aspects of service provision, reimbursement issues are an important part of any service provider’s job. If support is expected from LTC administrators, SLPs have to aid in managing the financial claim for services, which means SLPs must recognize the importance of the FMP, MDS evaluations, consistent charting, and intermediary regulations. Only then can therapists garner the support needed to provide their services.
6. Goals: potential outcomes of the therapeutic process Therapeutic goals for individuals with dementia must be focused on reducing activity limitations and participation restrictions (International Classification of Functioning, Disability and Health, 2001). These limitations and restrictions exist, in part, because of the effects of the cognitive impairments on functioning; however, the environment of the long-term care facility has an equally negative effect on communication. Kaakinen (1995) and colleagues discussed the lack of communication occurring among residents in LTC facilities and discovered several unwritten ‘‘rules’’ of conversational conduct that govern talking between residents, with the majority being classified as inhibitory (e.g., Do not talk to the opposite sex; Do not talk about yourself). Several other researchers also have commented on the limited opportunities for communication in LTC. Orange, Bouchard-Ryan, Meredith, & MacLean (1995) discussed communication in the LTC environment from the perspective of the Communication Predicament Model. In this model, age stereotypes and the resultant constraining behaviors of conversational partners are related to reduced quantity and quality of communication displayed by some older adults (Orange et al., 1995; Ryan, Kwong See, Meneer, & Trovato, 1992). Further, the authors contend that the communication predicament is most likely to occur in settings or situations that ‘‘elicit a negative prototype of aging’’ (p. 23); specifically, LTC settings.
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Therefore, when writing goals, SLPs must consider the resident within a communication milieu that includes formal caregivers, other residents, general staff, and visiting family members. The focus should be on educating potential conversation partners as to the abilities of the resident with dementia. Also, the SLP should create opportunities for conversation as part of a therapy program. For example, many family members and staff members lament that they don’t know how to have a conversation with a resident who has dementia. Indeed, it is difficult to talk with someone who cannot recall the context of the conversation, the name of the conversation partner, or her own intentions (Bayles & Tomoeda, 1993). However, by providing individuals with tangible stimuli such as photographs, memory wallets, or other personal belongings, conversational partners can focus more on the ‘‘here and now’’ (Bayles & Tomoeda, 1993) rather than relying on impaired episodic and working memory systems. The following is a typical impairment-based goal: Mr. Y will improve his recall of names to 90% accuracy with minimal cues from caregivers. This goal might be appropriate for someone who does not have a progressive neurological disease; however, for long-term care residents with dementia, a more appropriate goal would be the following: Mr. Y will answer simple choice and yes/no questions 100% of the time during menu selection in the dining room when prompted by servers. Both goals focus on improving communication, but the second activity-based goal focuses on preserved abilities such as semantic memory, auditory comprehension for simple material, recognition memory and familiar routines, all within the context of a meaningful activity of daily life. Recall that under the rules of a FMP, these goals should be selected by the SLP, in conjunction with the resident and caregivers when appropriate, and tasks to reach them implemented by other staff. Improving the communication of the resident with dementia involves ongoing staff training and education as to the benefit of social interactions for the resident and the caregiver, the most effective way to talk to residents with dementia during daily care activities, and the preserved abilities of individuals with dementia, even at the late stages of the decline.
7. Case illustrations: implicit learning and the functional maintenance program Two case studies of functional maintenance programs for residents with dementia exemplify the type of intervention that capitalizes on implicit learning and functional rehabilitation goals.
8. RB RB was an 84-year-old woman with dementia who was admitted to a skilled nursing facility for a short-term stay following hospitalization for pneumonia and
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other medical complications. Her prior level of function included living at home independently, though she did not drive and required assistance from a family member for shopping and errands. An evaluation of cognitive-communication functioning involved an interview with the resident and her son, along with administration of the Mini-Mental State Examination (MMSE: Folstein, Folstein, & McHugh, 1975), and the Functional Linguistic Communication Inventory (FLCI; Bayles & Tomoeda, 1994). Results revealed mild-moderate cognitive impairment with poor safety awareness, decreased judgment, inconsistent ability to follow directions, and poor ability to express basic needs. Strengths included reading simple sentences, comprehending one-part directions, reminiscing, and her motivation to return home. During a care plan meeting, two goals were identified as integral. First, RB needed to be able to recognize and respond in emergency situations and second, she had to be able to express basic needs regarding pain and discomfort. The first goal was important if she were ever to go home again. The second goal was important to improve her care while in the LTC facility and once at home at which time she would have regular phone conversations with her medical case manager. The SLP designed a FMP to teach RB to recognize and respond appropriately to emergency situations in role-play scenarios and to use a rating scale to express the severity of her shortness of breath and overall discomfort using SRT. A restorative nurses’ aid and the resident’s son were trained in the program and participated in therapy sessions. Skilled therapy was provided to assess, design, and train caregivers in the FMP in three sessions. RB then participated in therapy sessions five times per week for two weeks with the restorative nurses’ aid. Outcomes were positive. RB recognized emergency situations with 100% accuracy and followed a short written script for communicating over the phone. RB also demonstrated proficiency in using her rating scale with nursing staff and with her medical case manager during her home evaluation prior to discharge. The nursing staff reported that communication improved while RB was in the nursing facility as noted by decreased repetitive requests and vague reports of discomfort, and better medical management of pain and respiratory symptoms. Other therapy professionals including physical, occupational, and respiratory staff also capitalized on the use of the rating scale to improve communication.
9. SB SB was a 93-year-old male with Alzheimer’s disease who was transferred from an adult care home to a special care dementia unit in a skilled nursing facility. According to family and previous caregivers in the adult care home, he experienced a significant decline in function with an increase in verbal outbursts and agitation. Upon admission, the SLP screened the resident and requested a physician’s order to evaluate and establish a treatment program for SB to facilitate adjustment to his new living environment and to improve communication with
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his new caregivers. Generally, SB had few other medical complications, with the exception of a moderately-severe hearing loss. Following a comprehensive evaluation, including an environmental observation, SB was noted to have strengths in reading, writing, and conversing about topics of interest in environments free from distraction. In noisy situations, SB had a high incidence of aggressive behaviors. His hearing loss was a major contributor to his communication difficulty. He expressed frustration with the staff and the staff were unaware of the extent of his hearing loss. His problems were exacerbated by his refusal to wear his hearing aids. During a care plan meeting the following goals were selected: First, SB would be taught to reduce episodes of verbal outbursts by using compensatory techniques with staff. Second, staff would use three simple strategies to converse with SB (i.e., engage in conversation in quiet environments, repeat and rephrase what has been said, refer to written cues/labels during care routines). Spaced-retrieval training was used to teach SB to request repetition from communication partners if he didn’t understand what they had said. During training, a cue card with the statement ‘‘Say that again’’ was used. SB had to read the card when the SLP asked ‘‘What do you say if you don’t understand me?’’ After seven sessions, SB successfully demonstrated use of his (cue card) statement with staff in role-play conversation. Staff training involved education regarding effective communication with SB and included nurses’ aids and activities personnel. These interventions were incorporated into the care plan and nursing aides were instructed to chart how often they used the recommended strategies with SB each shift. Printed materials (i.e., guidelines and descriptions) on these communication strategies were included in the medical chart, the nurses’ aid daily charting book and the nurses’ daily medication logbook. (Other strategies to improve communication between residents with dementia and nursing home staff have been described by Dijkstra, Bourgeois, Burgio, and Allen (2002), and Burgio et al. (2001) and provide practical information useful in for education programs.) The ultimate outcomes of the FMP for SB were achieved. The frequency of his verbal outbursts and aggression towards staff members decreased and staff members reported increased satisfaction during communication with him. His use of a cue card not only prompted him to use the strategy, but also reminded staff to use their strategies when speaking with him. Although SB was unable to explicitly state when or how he learned his communication strategy, he implicitly learned it and applied it with the assistance of his communication partners.
10. Future trends in dementia care Societal level trends will undoubtedly have an influence on future practice patterns for older adults with AD. As the population of older adults grows, and the
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incidence and prevalence of AD increase, SLPs will need to focus on early intervention with caregivers and patients. Importantly, the practice of ‘‘aging-inplace’’ will necessitate the involvement of SLPs throughout the course of the disease process. Aging-in-place refers to remaining in the same place of residence as one ages and care needs change. This potentially means that individuals with dementia will live at home as long as possible, with the appropriate care provided through family member support, home-health care agencies, or day programs affiliated with LTC facilities. As a member of a health care team responsible for the care of individuals with dementia, SLPs will consult with family caregivers, individuals with dementia, and other team members to design cognitive-communication programs. Many professionals recommend changes to the physical environment to facilitate aging-in-place (e.g., wheelchair ramps, tub chairs, hand rails) but few modifications to the psychosocial environment are considered. Enriched environments with a focus on adaptations for changes in memory, attention and language that occur in dementia will be the responsibility of the SLP. How do these changes influence SLP practice? Specifically, SLPs will adopt more of a consultative and collaborative role with older adults with AD. The focus will be on providing comprehensive assessments of functioning that include consideration of individual life experiences and interests. Assessment information will be used as baseline data to follow functioning over time and to measure the effects of direct and indirect interventions (Clark, 1995) on people with AD and their caregivers. By its nature, consultation requires collaboration to be successful. SLPs will find themselves educating caregivers on techniques to optimize cognitive functioning and improve communication with the person with AD. In the coming years, collaborative models of care will require that SLPs adopt new roles in the community-based care of people with AD who are aging-in-place.
11. Conclusions The prevailing notion of Alzheimer disease as a diagnosis associated with ‘‘therapeutic nihilism’’ (Clark, 1995) is waning. Clinical researchers have demonstrated that despite marked deficits in explicit memory and learning systems, some individuals with dementia have relatively preserved implicit memory and learning. The preservation of implicit learning provides a strong rationale for interventions that promote improved communication for people with dementia. The theoretical motivation for interventions, coupled with knowledge of practical aspects of service delivery in LTC facilities, will enable speechlanguage pathologists to justify their skilled care of the resident with dementia and implement effective functional maintenance programs. The questions of what is a reasonable and necessary intervention for persons with dementia residing in
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LTC facilities remains. However, if SLPs select evidence-based treatments and appropriate goals and outcomes, many individuals with dementia will benefit from treatment. The ethical issue then surrounds the decision not to provide services to individuals with dementia solely on the basis of medical diagnosis.
Acknowledgments The author would like to thank Stuart Cleary, M.S. and Elizabeth Linos, M.S. for their assistance with the preparation of this manuscript. This paper was supported in part by a NIRG grant from the Alzheimer’s Association (USA). Appendix A. Continuing education 1. Which of the following types of memory is spared in AD? a. Working memory b. Non-declarative memory c. Semantic memory d. Episodic memory e. None of the above 2. Priming can be defined as: a. Recognition of a previously learned association b. Explicit recall of a previously presented stimulus c. When a later response is advantaged by presentation of an earlier related stimulus d. Feeling of familiarity upon seeing a previously presented stimulus e. None of the above 3. Why might it be important to constrain errors during implicit learning tasks? a. Implicit learning is disadvantaged by errors b. People with Alzheimer’s disease cannot ‘‘learn from their mistakes’’ c. It isn’t important to constrain errors during learning — errors are beneficial to the learning process in Alzheimer’s disease d. None of the above e. a and b 4. At a minimum, how many positive prognostic indicators are necessary to justify rehabilitation services in long-term care? a. One b. Two c. Three d. Four e. Five
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5. What future trend(s) will have an impact on speech-language pathology services to older adults with Alzheimer’s disease? a. Early institutionalization of people with cognitive impairments b. Shorter life expectancies c. Fewer rehabilitation professionals available to provide services to older adults d. Fewer services needed for older adults e. Older adults living longer at home and ‘‘aging-in-place’’
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Evans, J. J., Wilson, B. A., Schuri, U., Andrade, J., Baddeley, A., Bruna, O., Canavan, T., Della Salla, S., Green, R., Laaksonen, R., Lorenza, L., & Taussik, I. (2000). A comparison or errorless and trial-and-error learning methods for teaching individuals with acquired memory deficits. Neuropsychological Rehabilitation, 10(1), 67–101. Folstein, M., Folstein, S., & McHugh, P. (1975). ‘‘Mini-Mental State’’: A practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research, 12, 189–198. Glickstein, J. K., & Neustadt, G. K. (1995). Reimbursable geriatric service delivery: A functional maintenance therapy system. Gaithersburg, MD: Aspen Publishers. Health Care Financing Administration. (1991). Medicare and Medicaid requirements for long term care facilities. U.S. Government Restricted Rights. Heindel, W. C., Salmon, D. P., Shults, C. W., Walicke, P. A., & Butters, N. (1989). Neuropsychological evidence for multiple implicit memory systems: A comparison of Alzheimer’s Huntington’s and Parkinson’s disease patients. Journal of Neuroscience, 9, 582–587. Hopper, T., & Bayles, K. A. (2001). Management of neurogenic communication disorders associated with dementia. In R. Chapey (Ed.), Language intervention strategies in aphasia and related neurogenic communication disorders (4th ed.). New York, NY: Lippincott Williams & Wilkins. Hopper, T., Bayles, K. A., Harris, F. P., & Holland, A. (2001). The relationship of Minimum Data Set ratings to scores on measures of communication and hearing among nursing home residents with dementia. American Journal of Speech-Language Pathology, 10, 370–381. Hopper, T., & Bond-Moore, S., (2003). Errorless learning in Alzheimer’s disease. Poster presented at the annual meeting of the International Neuropsychological Society, Honolulu, Hawaii. International Classification of Functioning, Disability and Health. (2001). [On-line]. Available: http://www.cdc.gov/nchs/about/otheract/icd9/icfhome.htm. Judge, K. S., Camp, C. J., & Orsulic-Jeras, S. (2000). Use of Montessori-based activities for clients with dementia in adult day care: Effects on engagement. American Journal of Alzheimer’s Disease, 15(1), 43–46. Kaakinen, J. (1995). Talking among elderly nursing home residents. Topics in Language Disorders, 15(2), 36–46. Lawton, M. P. (1986). Environment and aging (2nd ed.). Albany, NY: The Center for the Study of Aging. McKitrick, L. A., Camp, C. J., & Black, F. W. (1992). Prospective memory intervention in Alzheimer’s disease. Journal of Gerontology: Psychological Sciences, 47(5), 337–343. Morris, J. N., Hawes, C., Fries, B. E., Phillips, C. D., Mor, V., Katz, S., Murphy, K., Drugovich, M. L., & Friedlob, A. S. (1990). Designing the national resident assessment instrument for nursing homes. The Gerontological Society of America, 30(3), 293–302. Orange, J. B., Bouchard-Ryan, E., Meredith, S. D., & MacLean, M. J. (1995). Application of the communication enhancement model for long-term care residents with Alzheimer’s disease. Topics in Language Disorders, 15(2), 20–35. Orsulic-Jeras, S., Judge, K. S., & Camp, C. J. (2000). Montessori-based activities for long term care residents with advanced dementia: Effects on engagement and affect. The Gerontologist, 40(1), 107–111. Pruchno, R. A., & Rose, M. S. (2000). The effect of long-term care environments on health outcomes. The Gerontologist, 40(4), 422–428. Ryan, E. B., Kwong See, S., Meneer, W. B., & Trovato, D. (1992). Age-based perceptions of language performance among younger and older adults. Communication Research, 19, 311–331. Saxton, J., McGonigle, K. L., Swihart, A. A., Boller, F. (1993). The severe impairment battery. Suffolk, UK: Thames Valley Test Company. Schacter, D. L., Rich, S. A., & Stampp, M. S. (1985). Remediation of memory disorders: Experimental evaluation of the spaced-retrieval technique. Journal of Clinical and Experimental Neuropsychology, 7, 79–96. Seger, C. (1998). Multiple forms of implicit learning. In M. A. Stadler & P. A. Frensch (Eds.), Handbook of implicit learning. Thousand Oaks, CA: Sage Publications.
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‘‘They’re just going to get worse anyway’’: perspectives on rehabilitation for nursing home residents with dementia Tammy L. Hopper* Department of Speech Pathology and Audiology, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, Alta., Canada T6G 2G4 Received 15 March 2003; received in revised form 15 May 2003; accepted 15 May 2003
Abstract In recent years, researchers have provided data to show that individuals with Alzheimer’s disease (AD) can learn new information and functional behaviors, despite significant declarative memory deficits. However, clinicians in long-term care frequently have difficulty justifying and providing needed services to persons with Alzheimer’s disease in LTC settings. In this paper, implicit learning will be discussed as a theoretical rationale to support rehabilitation along with practical issues related to the provision of speechlanguage pathology services for residents with Alzheimer’s disease in LTC settings. Learning outcomes: After reading this article, learners will be able to: (1) Define implicit learning; (2) discuss evidence for implicit learning in Alzheimer’s disease; (3) describe how to capitalize on implicit learning during rehabilitation for individuals with Alzheimer’s disease; (4) explain how to justify and provide interventions for individuals with Alzheimer’s disease in LTC settings. # 2003 Elsevier Inc. All rights reserved. Keywords: Implicit learning; Treatment; Alzheimer’s disease; Long-term care
Rehabilitation for dementia is plagued by misconceptions. Personal and professional caregivers of people with dementia often ask why they should support rehabilitation efforts when they know that the person with dementia is only ‘‘going to get worse’’ anyway. This situation is compounded by the fact that *
Tel.: þ1-780-492-0836; fax: þ1-780-492-9333. E-mail address: [email protected] (T.L. Hopper).
0021-9924/$ – see front matter # 2003 Elsevier Inc. All rights reserved. doi:10.1016/S0021-9924(03)00050-9
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many health care professionals, including speech-language pathologists (SLPs) share this view. In a recent survey of speech-language pathologists in Canada, 44% of respondents did not agree that individuals with dementia could benefit from speech-language pathology interventions (Cleary, Donnelly, Elgan, & Hopper, 2003). In fact, many rehabilitation professionals, long-term care administrators, and third party payers have stated that the provision of cognitive interventions for dementia is unethical as individuals with dementia cannot be expected to benefit from such interventions. In recent years, however, researchers have provided evidence that individuals with Alzheimer disease (AD) and other types of dementia can benefit from structured behavioral treatments that reduce demands on impaired cognitive abilities and capitalize on spared ones. The benefits of these interventions are observed in outcomes such as more time actively engaged in their environment and improved affect (Judge, Camp, & Orsulic-Jeras, 2000; Orsulic-Jeras, Judge, & Camp, 2000), improved ability to recognize or recall proper names (Brush & Camp, 1998a; Hopper & Bond-Moore, 2003; Vanhalle, Van der Linden, Belleville, & Gilbert., 1998), improved ability to carry out specific tasks (McKitrick, Camp, & Black, 1992; Zanetti et al., 1997), and reduced occurrence of negative verbal behaviors such as repetitive question-asking (Brush & Camp, 1998b). Despite these positive outcomes, little has been written regarding mechanisms of learning in Alzheimer’s disease and how implicit learning, a preserved form of learning in AD, may be used to promote improved function and justify cognitivecommunicative interventions. In this paper, implicit learning in AD will be discussed, followed by a summary of the reality of implementing therapy programs in long-term care facilities. Finally, implications for future research and clinical efforts will be discussed.
1. Implicit learning in Alzheimer’s disease By definition, individuals with Alzheimer’s disease have deficits in memory and learning. However, not all aspects of memory and learning are equally affected. Whereas semantic memory and non-declarative memory systems may be relatively intact until late in the disease process, episodic and working memory are diminished even in the early stages. As a result, explicit learning is adversely affected. Explicit learning is described as acquisition of knowledge under conditions in which the individual intends to learn (Schacter, Rich, & Stampp, 1985). For example, explicit learning occurs when individuals study conceptual associations for an exam, perhaps using strategies such as visual imagery and chunking of information, knowing that they will be tested on their knowledge of the information at a later time. Explicit tests of learning are ones that employ recall or recognition tasks (Buchner & Wippich, 1998). For example, an exam may consist of free recall (e.g., essay) and recognition (e.g., multiple-choice) questions. These tests are considered explicit tests because correct responding requires conscious
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recollection of previously studied events (Buchner & Wippich, 1998). Explicit learning is a manifestation of episodic memory and is therefore also prominently impaired in AD. However, implicit learning may be more intact. Implicit learning refers to the acquisition of knowledge or skills that is incidental (Seger, 1998). That is, during the acquisition phase of an implicit learning task, individuals are not intending to learn new information or behaviors. Thus, ‘‘. . . encoding occurs without the subject’s intention to learn, and learning is measured by the influence of that knowledge on another task . . . rather than being tested with recall or recognition’’ (Stadler & Roediger, 1998, p. 108). For example, after exposure to pictures of ‘‘things people wear,’’ Arkin, Rose, and Hopper (2000) found that individuals with AD named many of the pictured items on a generative naming task whereas before exposure to the pictures they had named few if any of them. This result is an example of priming, whereby a later response is advantaged by presentation of an earlier related stimulus. Although some researchers have argued that priming is impaired in individuals with AD (Heindel et al., 1989), evidence from clinical research suggests that implicit learning may be relatively preserved in this population. Several authors have reported positive learning gains using spaced-retrieval training (SRT) or repeated exposure to a stimulus-response pairing over expanding intervals of time. (See Bourgeois et al., accepted this volume, for a detailed review.) Specifically, SRT has been used to teach individuals with mild to moderately severe dementia a variety of associations such as names (Vanhalle et al., 1998), procedures (Hopper & Bayles, 2001), and compensatory strategies (Brush & Camp, 1998a; Camp, Foss, O’Hanlon, & Stevens, 1996). Whereas the SRT procedure is thought to rely upon implicit learning, as many individuals exhibit knowledge of the learned associations without explicit recall of the learning situation, explicit tests of recognition and recall are frequently used to assess this knowledge. That is, patients are directly asked about the association learned (e.g., ‘‘What is this person’s name? What do you do when you need to find out when lunch is served?). Thus, the patient may be learning implicitly but this learning is assessed explicitly. In recent work using recall and recognition tests in SRT, several individuals with moderate AD who could not recall a trained association could recognize it when given a choice, demonstrating implicit knowledge of the learned information though free recall was impaired (Hopper & Bond-Moore, 2003). It is important to consider the effects of the test situation when documenting learning gains in AD, as acquisition of new behaviors and information may not be apparent if tested using explicit recall tests.
2. Implicit learning and errors Whereas individuals with intact episodic memory may ‘‘learn from their mistakes,’’ implicit learning may be hampered by errors. Baddeley and Wilson (1994) suggest that individuals with episodic memory impairment, as in AD and
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other dementias, have difficulty eliminating errors made during learning trials because they cannot explicitly recall the learning experience; thus they continue to make the same errors on subsequent trials. The susceptibility of individuals with AD to the effects of interference may result in decreased ability to inhibit the production of prior error responses. The errorless learning technique has been used successfully with amnesic patients (Baddeley & Wilson, 1994; Wilson, Baddeley, & Evans, 1994) using word stem completion tasks. Additionally, Wilson et al. (1994), Evans et al. (2000) and Clare, Wilson, Breen, and Hodges (1999) reported positive learning outcomes in a series of studies in which errorless learning was used to teach practically relevant knowledge and skills, including face–name associations. Taken together, the evidence for preservation of implicit learning in AD is compelling and provides a strong rationale for cognitive-communication interventions for individuals with dementia. However, actual clinical implementation of such interventions in long-term care (LTC) settings requires knowledge not only of theory and research evidence but of the nature of service delivery in LTC environments.
3. Providing SLP Services in the LTC environment According to Medicare regulations for LTC facilities, nursing home residents must receive, and the facility must provide, care and services to maintain their highest practicable mental, physical, and psychosocial well-being, in accordance with a comprehensive assessment and care plan (Health Care Financing Administration, 1991). This requirement ensures that residents receive necessary rehabilitation services for the stated purposes of optimal care and functioning. However, in the past some Medicare intermediaries automatically denied rehabilitation services based solely on the ICD-9 diagnostic codes for dementia. The Centers for Medicare and Medicaid Services no longer allow intermediaries to deny claims on the basis of dementia diagnosis alone (CMS Transmittal AB-01-135, 2001), yet many therapists are reluctant to provide services to this populations. In their previously mentioned survey of Canadian SLPs, Cleary et al. (2003) also found that 60% believed that individuals with dementia could benefit from SLP interventions, yet the demands of treating other patients prevented them from providing services to persons with AD. This situation is now common in skilled nursing facilities in the U.S. as well. As the medical complexity of the average patient in LTC facilities increases, the demand increases for rehabilitation professionals to provide care to people who are transferred directly from the hospital. Individuals with dementia will not typically have the acuity that requires immediate rehabilitation efforts, unless that person has been re-admitted to the nursing home after a hospital stay for orthopedic or neurological reasons. Lack of referrals was also noted in the reasons for limited service provision to people with dementia. Seventy-five percent of respondents in the Cleary et al.
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(2003) survey stated that they did not routinely receive referrals to assess or treat individuals with dementia. Education of staff in LTC facilities, as well as physicians and other therapists, will help to increase the profile of the SLP and will improve awareness of the nature of services that the SLP can provide to residents with dementia.
4. How to intervene: the functional maintenance program — alive and well In 1995, Glickstein and Neustadt (1995) published a primer on a Functional Maintenance Program (FMP) for use in skilled nursing facilities. Clinicians develop a FMP based on a comprehensive evaluation of functioning of the person with dementia and train caregivers in program implementation. Whereas the Health Care Financing Administration (HCFA) has implemented several changes to reimbursement for rehabilitation for individuals in long-term care (i.e., PPS, cost-capitation for Medicare B recipients), the FMP remains viable as a mechanism for short-term, consultative intervention for individuals with dementia. According to the HCFA, a FMP is indicated when (1) a resident demonstrates a documented change in condition; (2) has a medical condition associated with loss of function; (3) is being discharged from skilled therapy and requires a directed intervention to maintain outcomes achieved during rehabilitation; and (4) requires skilled intervention to up-date an established program. Although FMPs are the primary method by which individuals with dementia receive skilled rehabilitation services, the culture of the nursing home is a barrier to effective implementation of communication-focused FMPs. Specifically, in a consultative model like a FMP, SLPs must rely on staff to continue the intervention once the skilled assessment and design of the program are completed. Though SLPs should consistently monitor and re-assess residents at regular intervals, certified nurses’ aides (CNAs) or restorative nurses’ aides are left to ensure the program recommendations are followed for each resident. Given the high turnover of nursing support staff in traditional LTC facilities and the high ratio of residents to staff caregivers, the success of the FMP is not ensured unless SLPs rely upon other individuals to provide support for their interventions. Staff who manage Activities departments in many long-term care facilities are logical choices for continuing provision of FMPs related to communication and cognition. Many goals of the FMP can be nested within activity programs and the structure of these programs is conducive to naturally occurring conversation with other residents, staff, and volunteers.
5. When to intervene The best time to develop a FMP for a person with dementia is upon admission to the LTC facility or when a significant change in function occurs. The SLP
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should be involved in the screening of each new resident and can interview family caregivers regarding any change in functional abilities coincident with the relocation. A substantial literature on transfer trauma indicates that involuntary moves of older persons from one facility to another can have detrimental effects on functioning (e.g., Lawton, 1986; Pruchno & Rose, 2000; Selzer, Sun, & Gutman, 2001). As many admissions to LTC facilities are frequently precipitated by a medical change in status (e.g., hip fracture, pneumonia), therapists should expect ‘‘de-compensation’’ or a decline in ability to perform activities of daily living, including communication. Changes in functional status also occur at other times for many reasons, among them loss of a loved one, depression, illness, and progression of the dementia. In addition to nursing documentation of these changes in status, other professionals such as speech-language pathologists, physical and occupational therapists must officially note a significant change in condition. Thus, if a therapist notes a decline in a residents’ ability to communicate for basic needs and/or social purposes, other team members should also note the change in their chart notes. If a significant change in function is noted in two or more areas, then a re-evaluation using the Minimum Data Set (MDS; Morris et al., 1990) is required. The MDS is a comprehensive assessment measure mandated for use in all LTC facilities receiving Medicare payments. The measure is completed for each resident upon admission, quarterly and annually and includes sections on Communication and Hearing, Cognitive Patterns, and Functional Rehabilitation Potential, among others. Bayles and Tomoeda (1997) recommended that clinicians use the MDS when working with people with dementia in LTC settings to develop programs and goals. However, in many settings, SLPs are not involved in MDS evaluations (Cleary & Hopper, 2000) and the information obtained on communication and hearing patterns of residents with dementia may not be accurate (Hopper, Bayles, Harris, & Holland, 2001). Without involvement in this mandated assessment process, SLPs may fail to recognize that a resident’s status in communication has changed and thus fail to receive appropriate referrals. A change in functional status is necessary to justify SLP interventions; however, it is not sufficient. There must also be a reasonable expectation of improvement as a result of the proposed intervention. In the HCFA Manual, 230.3, section A 2, regulations for provision of speech therapy services require that there must be an ‘‘expectation that the [resident’s] condition will improve significantly in a reasonable (and generally predictable) period of time.’’ With regard to dementia, this point deserves special emphasis. In all settings, including LTC, there must be indicators of positive prognosis for achievements of rehabilitation goals. This positive prognosis is usually documented in the ‘‘Functional Rehabilitation Potential’’ section of the MDS for those residents in skilled nursing facilities. If this section does not contain information that would lead a payer to believe that the resident could benefit from interventions (i.e., ‘‘poor’’ rehabilitation potential is indicated), then the claim for reimbursement will be denied. The most convincing rationale for intervening with residents with dementia is based
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on two positive prognostic indicators (e.g., potential to learn, family support, prior level of function). It is incumbent upon therapists to identify and document areas of strength upon which to capitalize in therapy. This information will demonstrate that residents with dementia have the potential to benefit from the planned intervention. Additionally, SLPs must identify communication abilities that may be vulnerable in the future and develop plans for scheduled screening and re-evaluation of skills. The idea is to target vulnerable skills with the hopes of staving off precipitous declines in communication abilities. The Functional Linguistic Communication Inventory (FLCI; Bayles & Tomoeda, 1994) allows clinicians to profile communication strengths and weaknesses, as well as abilities that are susceptible to decline in the future. Clinicians should utilize this or some other well-designed profile of functioning such as the Severe Impairment Battery (SIB; Saxton, McGonigle, Swihart, & Boller, 1993) to help design therapeutic programs with the goal of optimizing communication for as long a period as possible. Though many clinicians balk at the administrative or fiscal aspects of service provision, reimbursement issues are an important part of any service provider’s job. If support is expected from LTC administrators, SLPs have to aid in managing the financial claim for services, which means SLPs must recognize the importance of the FMP, MDS evaluations, consistent charting, and intermediary regulations. Only then can therapists garner the support needed to provide their services.
6. Goals: potential outcomes of the therapeutic process Therapeutic goals for individuals with dementia must be focused on reducing activity limitations and participation restrictions (International Classification of Functioning, Disability and Health, 2001). These limitations and restrictions exist, in part, because of the effects of the cognitive impairments on functioning; however, the environment of the long-term care facility has an equally negative effect on communication. Kaakinen (1995) and colleagues discussed the lack of communication occurring among residents in LTC facilities and discovered several unwritten ‘‘rules’’ of conversational conduct that govern talking between residents, with the majority being classified as inhibitory (e.g., Do not talk to the opposite sex; Do not talk about yourself). Several other researchers also have commented on the limited opportunities for communication in LTC. Orange, Bouchard-Ryan, Meredith, & MacLean (1995) discussed communication in the LTC environment from the perspective of the Communication Predicament Model. In this model, age stereotypes and the resultant constraining behaviors of conversational partners are related to reduced quantity and quality of communication displayed by some older adults (Orange et al., 1995; Ryan, Kwong See, Meneer, & Trovato, 1992). Further, the authors contend that the communication predicament is most likely to occur in settings or situations that ‘‘elicit a negative prototype of aging’’ (p. 23); specifically, LTC settings.
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Therefore, when writing goals, SLPs must consider the resident within a communication milieu that includes formal caregivers, other residents, general staff, and visiting family members. The focus should be on educating potential conversation partners as to the abilities of the resident with dementia. Also, the SLP should create opportunities for conversation as part of a therapy program. For example, many family members and staff members lament that they don’t know how to have a conversation with a resident who has dementia. Indeed, it is difficult to talk with someone who cannot recall the context of the conversation, the name of the conversation partner, or her own intentions (Bayles & Tomoeda, 1993). However, by providing individuals with tangible stimuli such as photographs, memory wallets, or other personal belongings, conversational partners can focus more on the ‘‘here and now’’ (Bayles & Tomoeda, 1993) rather than relying on impaired episodic and working memory systems. The following is a typical impairment-based goal: Mr. Y will improve his recall of names to 90% accuracy with minimal cues from caregivers. This goal might be appropriate for someone who does not have a progressive neurological disease; however, for long-term care residents with dementia, a more appropriate goal would be the following: Mr. Y will answer simple choice and yes/no questions 100% of the time during menu selection in the dining room when prompted by servers. Both goals focus on improving communication, but the second activity-based goal focuses on preserved abilities such as semantic memory, auditory comprehension for simple material, recognition memory and familiar routines, all within the context of a meaningful activity of daily life. Recall that under the rules of a FMP, these goals should be selected by the SLP, in conjunction with the resident and caregivers when appropriate, and tasks to reach them implemented by other staff. Improving the communication of the resident with dementia involves ongoing staff training and education as to the benefit of social interactions for the resident and the caregiver, the most effective way to talk to residents with dementia during daily care activities, and the preserved abilities of individuals with dementia, even at the late stages of the decline.
7. Case illustrations: implicit learning and the functional maintenance program Two case studies of functional maintenance programs for residents with dementia exemplify the type of intervention that capitalizes on implicit learning and functional rehabilitation goals.
8. RB RB was an 84-year-old woman with dementia who was admitted to a skilled nursing facility for a short-term stay following hospitalization for pneumonia and
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other medical complications. Her prior level of function included living at home independently, though she did not drive and required assistance from a family member for shopping and errands. An evaluation of cognitive-communication functioning involved an interview with the resident and her son, along with administration of the Mini-Mental State Examination (MMSE: Folstein, Folstein, & McHugh, 1975), and the Functional Linguistic Communication Inventory (FLCI; Bayles & Tomoeda, 1994). Results revealed mild-moderate cognitive impairment with poor safety awareness, decreased judgment, inconsistent ability to follow directions, and poor ability to express basic needs. Strengths included reading simple sentences, comprehending one-part directions, reminiscing, and her motivation to return home. During a care plan meeting, two goals were identified as integral. First, RB needed to be able to recognize and respond in emergency situations and second, she had to be able to express basic needs regarding pain and discomfort. The first goal was important if she were ever to go home again. The second goal was important to improve her care while in the LTC facility and once at home at which time she would have regular phone conversations with her medical case manager. The SLP designed a FMP to teach RB to recognize and respond appropriately to emergency situations in role-play scenarios and to use a rating scale to express the severity of her shortness of breath and overall discomfort using SRT. A restorative nurses’ aid and the resident’s son were trained in the program and participated in therapy sessions. Skilled therapy was provided to assess, design, and train caregivers in the FMP in three sessions. RB then participated in therapy sessions five times per week for two weeks with the restorative nurses’ aid. Outcomes were positive. RB recognized emergency situations with 100% accuracy and followed a short written script for communicating over the phone. RB also demonstrated proficiency in using her rating scale with nursing staff and with her medical case manager during her home evaluation prior to discharge. The nursing staff reported that communication improved while RB was in the nursing facility as noted by decreased repetitive requests and vague reports of discomfort, and better medical management of pain and respiratory symptoms. Other therapy professionals including physical, occupational, and respiratory staff also capitalized on the use of the rating scale to improve communication.
9. SB SB was a 93-year-old male with Alzheimer’s disease who was transferred from an adult care home to a special care dementia unit in a skilled nursing facility. According to family and previous caregivers in the adult care home, he experienced a significant decline in function with an increase in verbal outbursts and agitation. Upon admission, the SLP screened the resident and requested a physician’s order to evaluate and establish a treatment program for SB to facilitate adjustment to his new living environment and to improve communication with
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his new caregivers. Generally, SB had few other medical complications, with the exception of a moderately-severe hearing loss. Following a comprehensive evaluation, including an environmental observation, SB was noted to have strengths in reading, writing, and conversing about topics of interest in environments free from distraction. In noisy situations, SB had a high incidence of aggressive behaviors. His hearing loss was a major contributor to his communication difficulty. He expressed frustration with the staff and the staff were unaware of the extent of his hearing loss. His problems were exacerbated by his refusal to wear his hearing aids. During a care plan meeting the following goals were selected: First, SB would be taught to reduce episodes of verbal outbursts by using compensatory techniques with staff. Second, staff would use three simple strategies to converse with SB (i.e., engage in conversation in quiet environments, repeat and rephrase what has been said, refer to written cues/labels during care routines). Spaced-retrieval training was used to teach SB to request repetition from communication partners if he didn’t understand what they had said. During training, a cue card with the statement ‘‘Say that again’’ was used. SB had to read the card when the SLP asked ‘‘What do you say if you don’t understand me?’’ After seven sessions, SB successfully demonstrated use of his (cue card) statement with staff in role-play conversation. Staff training involved education regarding effective communication with SB and included nurses’ aids and activities personnel. These interventions were incorporated into the care plan and nursing aides were instructed to chart how often they used the recommended strategies with SB each shift. Printed materials (i.e., guidelines and descriptions) on these communication strategies were included in the medical chart, the nurses’ aid daily charting book and the nurses’ daily medication logbook. (Other strategies to improve communication between residents with dementia and nursing home staff have been described by Dijkstra, Bourgeois, Burgio, and Allen (2002), and Burgio et al. (2001) and provide practical information useful in for education programs.) The ultimate outcomes of the FMP for SB were achieved. The frequency of his verbal outbursts and aggression towards staff members decreased and staff members reported increased satisfaction during communication with him. His use of a cue card not only prompted him to use the strategy, but also reminded staff to use their strategies when speaking with him. Although SB was unable to explicitly state when or how he learned his communication strategy, he implicitly learned it and applied it with the assistance of his communication partners.
10. Future trends in dementia care Societal level trends will undoubtedly have an influence on future practice patterns for older adults with AD. As the population of older adults grows, and the
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incidence and prevalence of AD increase, SLPs will need to focus on early intervention with caregivers and patients. Importantly, the practice of ‘‘aging-inplace’’ will necessitate the involvement of SLPs throughout the course of the disease process. Aging-in-place refers to remaining in the same place of residence as one ages and care needs change. This potentially means that individuals with dementia will live at home as long as possible, with the appropriate care provided through family member support, home-health care agencies, or day programs affiliated with LTC facilities. As a member of a health care team responsible for the care of individuals with dementia, SLPs will consult with family caregivers, individuals with dementia, and other team members to design cognitive-communication programs. Many professionals recommend changes to the physical environment to facilitate aging-in-place (e.g., wheelchair ramps, tub chairs, hand rails) but few modifications to the psychosocial environment are considered. Enriched environments with a focus on adaptations for changes in memory, attention and language that occur in dementia will be the responsibility of the SLP. How do these changes influence SLP practice? Specifically, SLPs will adopt more of a consultative and collaborative role with older adults with AD. The focus will be on providing comprehensive assessments of functioning that include consideration of individual life experiences and interests. Assessment information will be used as baseline data to follow functioning over time and to measure the effects of direct and indirect interventions (Clark, 1995) on people with AD and their caregivers. By its nature, consultation requires collaboration to be successful. SLPs will find themselves educating caregivers on techniques to optimize cognitive functioning and improve communication with the person with AD. In the coming years, collaborative models of care will require that SLPs adopt new roles in the community-based care of people with AD who are aging-in-place.
11. Conclusions The prevailing notion of Alzheimer disease as a diagnosis associated with ‘‘therapeutic nihilism’’ (Clark, 1995) is waning. Clinical researchers have demonstrated that despite marked deficits in explicit memory and learning systems, some individuals with dementia have relatively preserved implicit memory and learning. The preservation of implicit learning provides a strong rationale for interventions that promote improved communication for people with dementia. The theoretical motivation for interventions, coupled with knowledge of practical aspects of service delivery in LTC facilities, will enable speechlanguage pathologists to justify their skilled care of the resident with dementia and implement effective functional maintenance programs. The questions of what is a reasonable and necessary intervention for persons with dementia residing in
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LTC facilities remains. However, if SLPs select evidence-based treatments and appropriate goals and outcomes, many individuals with dementia will benefit from treatment. The ethical issue then surrounds the decision not to provide services to individuals with dementia solely on the basis of medical diagnosis.
Acknowledgments The author would like to thank Stuart Cleary, M.S. and Elizabeth Linos, M.S. for their assistance with the preparation of this manuscript. This paper was supported in part by a NIRG grant from the Alzheimer’s Association (USA). Appendix A. Continuing education 1. Which of the following types of memory is spared in AD? a. Working memory b. Non-declarative memory c. Semantic memory d. Episodic memory e. None of the above 2. Priming can be defined as: a. Recognition of a previously learned association b. Explicit recall of a previously presented stimulus c. When a later response is advantaged by presentation of an earlier related stimulus d. Feeling of familiarity upon seeing a previously presented stimulus e. None of the above 3. Why might it be important to constrain errors during implicit learning tasks? a. Implicit learning is disadvantaged by errors b. People with Alzheimer’s disease cannot ‘‘learn from their mistakes’’ c. It isn’t important to constrain errors during learning — errors are beneficial to the learning process in Alzheimer’s disease d. None of the above e. a and b 4. At a minimum, how many positive prognostic indicators are necessary to justify rehabilitation services in long-term care? a. One b. Two c. Three d. Four e. Five
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5. What future trend(s) will have an impact on speech-language pathology services to older adults with Alzheimer’s disease? a. Early institutionalization of people with cognitive impairments b. Shorter life expectancies c. Fewer rehabilitation professionals available to provide services to older adults d. Fewer services needed for older adults e. Older adults living longer at home and ‘‘aging-in-place’’
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