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Outline y Review of ; Language, Cognitive, Behavior changes y Brief discussion of Assessment for Functional Treatment y Theoretical Models underlying Functional Treatment y Treatment approaches: Evolution of Memory Books Michelle S. Bourgeois, Ph.D., CCC‐SLP Ohio State University y Developing Functional Goals for Long‐term Care [email protected] y Case Examples

Diagnostic Criteria for Dementia: Diagnostic and Statistical Manual of Mental Disorders ‐IV Differentiating the effects of normal aging from (DSM‐IV; APA, 2000) dementia y Memory impairment and related changes in another cognitive domain y Reversible and/or Treatable Conditions (language, abstract thinking, judgment, executive functioning) that are y Rule out and treat metabolic and nutritional disorders, , other disease processes and medical conditions y sufficiently severe to cause impairment in social and occupational functioning, y Age‐Associated Memory Impairment y and that reflect a decline from a previously higher level of y Rule out depression and dementia functioning. y < 1 standard deviation below mean of young adult scores on cognitive tests y Cognitive and behavioral symptoms are y Slower psychomotor speed; benign forgetfulness y chronic and progressive, y Preserved occupational and social functioning y may be correlated with specific neuropathology of an organic basis, y Mild Cognitive Impairment y are differentiated from disturbances of consciousness (e.g., ) y Increased frequency of memory complaints or psychiatric etiologies (e.g., depression, anxiety disorders) for which y Preserved occupational and social functioning there are pharmacological treatments (Ballard, 2000). y < 1.5 standard deviations below mean of age and education matched healthy controls on cognitive tests

Alzheimer’s Disease (AD) (VaD) (FTD) Characteristics of Cognitive‐Communication changes in Prevalence 60-70% of cases 15-30% of cases 8-20%

Aphasia and Dementia: Dementia Onset Slow, Gradual progression Abrupt, stepwise progression Slow, Gradual Cognition Memory Deficits: Focal symptoms: Variable word finding (early) Some early; others late Disorder of Cognition Short-term (mid) y Memory Loss is the Core Symptom of most types of Long-term (late) Executive dysfunction (early) Mild executive dysfunction; Selective and sustained Dementia Severe & early in attention deficits (early) Binswanger’s disease Greater deficits than AD y Other Symptoms include: Language Intact; mild word finding (early) Focal language deficits variable Intact (early) y Language problems Perseverative, echolalic, Semantics, pragmatics, reading Co-occurs with extrapyramidal mutism (late) y comprehension, perseveration symptoms, gait problems, Primary progressive aphasia: Attention, Executive function, visuospatial (mid) paresis, facial weakness early, nonfluent, language difficulties deficits Affective responses only (late) Semantic Dementia: late, y Troublesome behaviors: wandering, agitation, fluent language deficits irritability, , day‐night disorientation Visuospatial Progressive decline Visual field deficits Intact (early) Behavior Personality, mood changes (early) Depression, agitation, anxiety, Profound early changes in y Depression Delusions, hallucinations, apathy (early) mood, personality and social agitation, repetitive (mid) conduct Ambulation, sleep, eating (late)

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Dementia with Lewy Bodies Dementia in Parkinson’s (DLB) Disease Prevalence 20-30% 18-40% of Parkinson’s patients Onset Slow, Gradual Slow, Gradual and fluctuating More dementia types Cognition Intact (early) Similar to DLB Gradually fluctuating Fluctuating Cognition y Dementia in Huntington’s disease Similar to AD y Human immunodeficiency virus‐associated dementia Attention (early) Executive dysfunction (early) Executive dysfunction (early) (HIV‐D)

Language Verbal fluency deficits (early) Less language impairment than y Creutzfeldt‐Jakob disease (CJD) Otherwise intact (early) AD y Similar to AD Early pragmatic deficits Pseudo dementia Extrapyramidal symptoms: y Other Co‐morbidities resting tremor, bradykinesia, cogwheel rigidity y Heart disease Visuospatial Deficits (early) y Hip Fracture y Diabetes y CVA, stroke Behavior Visual hallucinations, delusions, Depression, mood changes depression (early) Medication related delusions y Lung diseases and hallucinations

Communication and Cognitive Deficits and Strengths of Persons with AD Communication and Cognitive Deficits Communication and Cognitive Strengths Early Stage Behavior Problems Mild expressive language deficits related to word- Phonology, Syntax, Pragmatics intact finding problems for names, places Oral reading and writing intact Receptive language: difficulty comprehending abstract Intact comprehension of concrete language are symptoms of Memory, Language, & Cognitive Deficits language and complex conversation Good reading comprehension Memory: Mild declarative/explicit memory retrieval Intact nondeclarative/implicit and sensory memory deficits Aware of language and memory lapses Executive function: inconsistent problems with IADLs Good sustained attention and concentration y Frequency, intensity, severity, and pattern vary by (finances, shopping) Divided and selective attention lapses person, etiology, stage of disease, and Mild visuospatial deficits

Middle Stage environmental factors Increasing expressive language deficits; word-finding Phonology and Syntax intact problems, lack of content in conversation Oral reading for familiar text preserved y Early stage –memory issues, fearful, irritable, Pragmatic difficulties with topic maintenance Reading comprehension good for familiar words and Receptive language: difficulty comprehending complex phrases instructions, tasks Adequate nondeclarative/implicit and sensory memory personality changes, mood swings Reading comprehension difficulties Memory: Increasing declarative memory retrieval deficits y Middle stages –problems more diverse, frequent, Executive function: lack of inhibition, planning and set shifting problems and difficult to manage Attention: impaired in all domains Visuospatial: increasing problems Late Stage y Late stages –behaviors slow down, more Expression of needs and wants: may be inappropriate Appropriate affective responses to sensory stimuli, verbal or vocal productions; mutism at end music (smiles, pleasant vocalization) predictable and manageable, related to nursing stage Cooperates with appropriate cues (tactile, visual, Repetitive vocal and physical behavior affective) care Severely limited auditory comprehension Basic needs for attention, communication, touch present Severe memory deficits across domains Impaired attention, fluctuating alertness

Assessment: The Role of SLP in Dementia Need‐Driven Compromised Behavior Model (Algase et al, 1996) y Diagnosis vs. Treatment: Historical perspective y Theory of Unmet Needs y International Classification of Functioning, Disability and Health (ICF) (WHO; 2001) y Personal, social, environmental, physical, y Body structures and function/Impairment emotional needs y Physiology and anatomy y Activity/Activity Limitations y Cannot communicate effectively due to y Execution of a task or action by an individual language and cognitive changes y Participation/Participation Restriction y Involvement in a life situation y Behaviors are expressions of need y y Assessment for Treatment Planning Misinterpreted as maladaptive y Determine preserved skills & deficits

y MOST Behavior problems can be addressed with y Planning Functional Assessment to Address Functional Communication‐based treatments Outcomes y Determine desired outcomes for maintaining function

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Assessment at the Activity & Participation Levels Purposes of Assessment y Identify patient y To provide a baseline measure of cognitive‐ y limitations in communication & activities of daily communicative functioning against which to measure living progress y strengths in communication & functioning y To identify and profile cognitive‐linguistic strengths and y problem behaviors (anxieties, repetitive questions and weaknesses around which goals and a treatment plan are behaviors, social isolation) developed y environmental barriers for communication y To provide a diagnosis and prognosis, when possible y desired activities and participation y Assessment should not take place only at pre and post y treatment evaluation sessions, but whenever there is a Interview the Caregivers for behavior complaints documented change in status and expectations y These will lead to potential goals for treatment programs

Determine frequency of problem: Identify Problem Behaviors Behavior Diary Behavior Log

Date Time Describe the Behavior How Day Count Problem: Count y Identify, describe, and count frequency of Often? Cannot find Problem: room Asks what caregiver and patient complaints. time it is. y What are the specific problems? Monday y Where do they occur; what time of day? Tuesday y How often do they occur? y What is the consequence of the problem; who says and Wednesday does what; does it work? Thursday y What is causing this problem; activity limitation? y What impact does this problem have on quality of life Friday (participation in desired activities)? Saturday

Sunday

Identify Environmental Barriers Determine Desired Range of Participation Environment/ People Frequency Problems Environment & Activity of Contact Communication Home Me 24-7 Lots of Wife, Mary arguments Assessment Toolkit Loss of intimacy for Dementia Care Church Minister, Friends: Bob & Sunday, Can’t remember Jane Smith, H. Jones, Tuesday names many others Choir By Jennifer Brush, M.A., CCC/SLP; Practice Margaret Calkins, Ph.D., CAPS, EDAC; Carrie Bruce, M.A., CCC/SLP, ATP; and Senior Center Men’s Group Wednesday Names, following Jon Sanford, M.Arch. conversation

Includes: Grocery Store Clerk varies Giving correct Sound level meter money Light meter Son’s home Son, Spouse Once/week Yells at kids Personal Spaces Assessment Forms T.(6 yrs), M. (2 yrs) Public Spaces Assessment Forms

2011, Health Professions Press

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Daily Schedule/Routines Functional Goals Screening Protocol: Community Clients with Dementia Monday Tuesday Wednesday Thursday Friday Saturday Sunday © Michelle Bourgeois, Ph.D. CCC-SLP & Angela Halter Rozsa, M.S. CCC-SLP Name: ______Date of Screening: ______8 am Breakfast Medical Diagnosis: ______Dressed Date of Birth: ______Age: ______Gender: ______PART 1: CLIENT INTERVIEW 9 am A. Personal Information 10 am Senior Senior Church Center Center Family Occupation 11 am Noon Lunch Lives with: Hobbies 1 pm 2 pm Friends Activities 3 pm Preferences Dislikes 4 pm 5 pm Dinner Dinner Dinner Dinner Dinner Dinner Premorbid Basic Reading Ability Yes No Unable to answer 6 pm TV News Dinner at Premorbid Basic Writing Ability Yes No Unable to answer Son’s house Wears Hearing Aid Yes No Wears glasses Yes No For some activities 7 pm Choir Other languages spoken Yes No Other: ______Practice B. MMSE Score: ______Mild=20-23; Moderate=17-19; Severe= <17 8 pm Strengths: ______Weaknesses: ______9 pm 10 pm 11 pm Bed Bed Bed Bed Bed Bed Bed

C. Conversational Sample: Tell me about your family (or what you did for a living): Assess to determine Expectation for Treatment Effects

Discourse features Present Absent No opportunity Bourgeois Oral Reading Measure (1992) Takes turns ______Relinquishes turn ______Maintains topic ______Initiates new topic ______Transitions from topic ______Requests clarification ______Clarifies ______D. Orientation to Environment: Show me where the bathroom is? Able Requires assistance (Mild Mod Max) Not able Show me where your telephone is? Able Requires assistance (Mild Mod Max) Not able Show me where I can get a glass of water? Able Requires assistance (Mild Mod Max) Not able E. Auditory and Tactile Behaviors: Is attentive when others are talking? Yes No Holds, squeezes, manipulates objects? Yes No Is bothered by noises (radio, tv)? Yes No Rubs, smooths, explores surface with hands? Yes No Is attentive to or participates in music, singing? Yes No Hits, bangs, slaps objects or surfaces? Yes No F. Visual and Functional Reading Behaviors: (Use newspaper, magazine, other written materials in the home) Prompt client to “Tell me something interesting from this paper (magazine, mail, etc.) Does client read aloud from the materials? Yes No Does client make comments about the topic? Yes No Complete form in Handouts

Informal Reading Assessment More Informal Reading Assessment Today is August 5, 2010. (40) Your money is safe There is a cool breeze blowing. (36) in the bank.

Buffalo are grazing on the plain. (24) My money is safe in Your money is safe in the bank. Ice cream would be a refreshing treat. (18) the bank.

Let’s have a picnic near the swimming hole. (12) Don’t worry –it’s safe.

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Spaced‐Retrieval Screening (Brush & Camp, 1998) Assessment Results Determine Candidacy „1. (NO DELAY) “Today we are going to practice remembering my name. My name is______. What is my name?” for Treatment „Correct: “That’s right. I am glad that you remembered.” y Intervene with individuals who: „2. (SHORT DELAY) “Good. I will give you more opportunities to practice as I am working y Show intent to communicate with you today. Let’s try again. What is my name?” „Correct: “That’s right. I am glad that you remembered y Demonstrate cognitive‐linguistic strengths around which to structure a treatment program „3. (LONG DELAY) “You are doing well remembering my name for a longer period of time, and that’s the idea. I would like you to always remember my name. I will y Respond to cues be practicing this with you during therapy by asking you often. What is my name?” y Follow simple directions „Correct: “That’s right you are remembering for a longer period of time. You did a great job y Exhibit recent/significant change in status remembering my name.

„If the client is incorrect at any level 3 times in a row, this client is not appropriate for SR training, say: “Thanks for trying so hard. Let’s work on something else now.”

Guiding Principles for Functional Theoretical basis for these intervention effects Intervention y WHO Model (WHO, 2002): y Impairment, Activity, Participation y Maintain independent functioning as long as possible y Maintain quality of life via supported participation and y Memory Model (Baddeley, 1995) engagement y Preserved and Impaired memory systems y Emphasize personal relevance and contextual training y Sensory, Short term/Working, Long term memory y A theory of Learning (Squire, 1994)

y Person‐Centered Care Model (Kitwood, 1997): y People need comfort, attachment, inclusion, occupation, and identity

Theoretical rationale for intervention WHO model of Treatment in Dementia y Impairment level treatment strategies: A memory model y Pharmacological y Preserved memory systems y Change language, cognition, memory processes? y Poor maintenance as disease progresses y Enhance strength areas y Activity level treatment y Impaired memory systems y Non‐Pharmacological y Support compensatory strategies for functional behaviors y Reduce demands on impaired systems by using cues and y Modify cues and environment compensatory strategies y Participation level treatment y Increase participation and engagement in desired activities y Improves quality of life

Treatment needs to be appropriate: for the settings (Environmental factors) and for the person (Personal factors: person‐centered approach)

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A Model of Memory for Dementia (Baddeley, 1995) y Sensory memory y Problems with recognition and identification y Early stages: relatively preserved y Later: need to enhance sensory cues y Short term memory (working, temporary) y Problems with encoding and decoding y Early stages: most impaired y Reduce demands with memory aids and strategies y Long term memory (semantic, episodic, and procedural) y Problems with retrieval y Early stages: word retrieval problems y Later stages: procedural memories relatively preserved y Enhance cues and Reduce demands with memory aids

Classifying language deficits and problem behaviors Memory Strategies can be… by memory subsystem

Sensory memory: Problems Short term, temporary Long term, semantic, episodic, INTERNAL STRATEGIES EXTERNAL STRATEGIES with registration, recognition, working memory: problems and procedural memory: and identification with encoding/decoding Problems with retrieval Mnemonics Calendar, planner, diary Visual agnosia: does not Repetitive questions; failure to Word-finding problems: specific recognize common objects; encode answer words, facts, names of Face-Name associations Multifunctional watch, timers puts objects in wrong Follows caregiver; forgets familiar persons, places, and places caregiver is temporarily in events; Uses wrong name Mental retracing of events Shopping lists, string on finger : does not the other room States erroneous information; recognize his home Uncooperative, may not lying and accusations First letter associations Putting things in a special place Repetitive tactile manipulation; follow directions or Disruptive vocalization; inability does not recognize object instructions: failure to to access words to express Memory games and drills Signs, labels, notes Delusions; misidentifies encode or decode verbal wants and needs people, objects, places stimuli Forgets how to dress, bathe, Tape recording Hallucinations; sees people, Agitation, pacing: failure to feed, toilet self objects that are not there encode responses to Forgets how to use telephone, Distracted by competing anxiety induced behavior other familiar implements sensory stimuli; sensory Does not complete tasks overload Apathy; forgets what to do Wandering: forgets where to go

y Internal Strategies External Strategies require: require: External Aids for Sensory Memory y Effortful, conscious processing Automatic processing Visual cues, Auditory cues y Active memory search to recall Recognition based on Tactile cues, Olfactory cues experience & practice y Internal monitoring of info External monitoring of info Familiar objects, sounds, smells… y Mental representation Physical, permanent trigger memories… products Over learned memories are most y Inside the Brain In the Environment resistant to neurological disease

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Visual Aids Written Cues: Notes, Labels, Lists, Signs Organizational Cues: Planners, Medication boxes Environmental Cues: Objects, color‐coding, special places

Calendars, calendars….

Auditory Aids for Sensory Memory

Tactile Aids for Short term Memory Problems: Sensory Memory Getting information into Memory

•Repetitive questions

•Forgets information quickly

•Does not follow directions or instructions

•Lack of cooperation, refuses, makes excuses

•All are examples of failure to encode, or get information into Memory

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Aids for Encoding Information:

Shopping Organizers Grocery List Vegetables Dairy Written information can Meats Breads be re‐read repeatedly Canned goods Paper

Frozen foods Pet food

More Aids for Memory Encoding: reminder cards & memo boards

My wife Jane lost her Low tech and higher tech aids for encoding valiant fight with cancer on May 10, 1999 and information rests peacefully here.

I walk with a cane for safety.

A Common Problem… Ways to practice… …..Learning New Information using Memory Aids y Talk about memory cues in the environment; read All Memory Aids must …… them out loud together. ‐ be Attractive to the user ‐ be Desirable to the user y Use rehearsal strategies, like Spaced Retrieval ‐ perform a useful function y ( Camp et al., 1996; Brush & Camp, 1998) ‐ be Needed frequently, every day y “What do you do to remember where I am?” y “I read the memo board.” And….You need y “What do you do to walk safely?” to incorporate training, rehearsal, and repetitive practice y “I walk with my cane.” to ensure learning of desired information Practice, practice, practice!

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Retrieval from Long term memory Memory Aids for Information Retrieval: Organizational aids & Planners •Word-finding problems: specific words, facts, names, places, events

•Forgets previously learned information

•Forgets how to use telephone, other familiar implements

•Forgets how to get to familiar places

•Forgets how to dress, bathe, feed, toilet self

Memory Books Memory Wallets

Bourgeois, 1990

Text can address Problem Behaviors Modifying the text maintains function Caregiver reported Problem Behaviors: y Repetitive Questions y Where is my wife? y Where are we going today? y Restlessness, Pacing y Places to go…things to do. y Delusions, Hallucinations y You are not my husband. y There’s a construction crew in the backyard.

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Reminder Cards Problem in the : Memory Books are not used by Residents or Nursing Aides Solutions: 1. Make them more functional y Add Orientation information y Add Activity of Daily living information

My wife Jane lost her y Add Problem Behavior Resolution Info. valiant fight with cancer Buster was my favorite y Give Nursing Aide ownership on May 10, 1999 and dog. He was my best friend for many years. rests peacefully here. 2. Make them more portable 3. Establish use through training (Spaced Retrieval)

Functional & Portable Memory Aids

Wearable Memory Aids

Eating keeps me healthy and strong. Bourgeois, M., Dijkstra, K., Burgio, L., & Allen-Burge, R. (2001). Memory aids as an AAC strategy for nursing home residents with dementia. Augmentative and Alternative Communication, 17, 196-210.

y Trained Nursing Aides to use Memory Cards during care interactions y RESULTS: Showering makes me feel fresh and clean. y Improved quantity and quality of interaction y Nursing Aides & Residents talked more y Nursing Aides used more facilitative behaviors y Nursing aides’ judgment of resident depression improved

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Music activities The bathroom is are free. next to my room.

Movie Pass Movie Pass Meal Ticket ______Monday Good for 1 ______Tuesday Burgio, L., Allen‐Burge, R., Roth, D., Bourgeois, M., Dijkstra, K., Gerstle, J., Jackson, FREE ______Wednesday Movie ______Thursday E., & Bankester, L. (2001). Come talk with me: Improving communication between ______Friday nursing assistants and nursing home residents during care routines. The Movie pass Movie pass ______Saturday Gerontologist, 41, 449‐460. ______Sunday

Countdown to Laundry Day… √ I changed my clothes. Memo Boards Interest & Hobby Albums √ I changed my clothes. I changed my clothes.

I changed my clothes.

I changed my clothes.

I changed my clothes.

Laundry Day!

I need to change my clothes everyday.

Need‐Driven Compromised Behavior Model (Algase et al, 1996) y Theory of Unmet Needs y Personal, social, environmental, physical, emotional needs y Cannot communicate effectively due to language and cognitive changes y Behaviors are expressions of need y Misinterpreted as maladaptive

y MOST Behavior problems can be addressed with Other uses of Written Cues: Reading Games Communication‐based treatments Montessori Sorting Game (Camp, 1999)

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What types of Orientation goals do you Problem Behaviors & Goal Writing write? y Orientation y Orientation to person? y Wants & Needs y Orientation to place? y Engagement & Activities y Orientation to time? y Problem Behaviors y Nursing Home y Home & Family

Orientation to person Orientation Assessment Form (Bourgeois, 2006) Assessing the Orientation Behaviors of: (name) J.P. Past Behaviors for Location/Profession: Desired Behaviors for location/activities: home, Retired Lawyer drives to golf course, doctors, and church Person: Supports: Person Supports: Medic Alert Oriented to person Driver’s license Needs personal Driver’s license I am Melissa Browning. identity information Wallet identity card I am diabetic. Please call Place: Used maps some Place Written address by (333)111-2222 Oriented to place Used GPS in car Needs written location telephone & in wallet information for Driving Directions This is me at 3. This is me now. emergency use Notebook for car Orientation to Place: Physical Location Needs written supports (immediate, residence, community) for directions to I live at familiar locations Orientation to time 314 Elm Street. Time: -Wrist watch Time Consolidate electronic Oriented to time - Outlook calendar on Needs to keep daily systems (computer, computer appointments PDA, or cell phone) - PDA (personal digital Worried about taxes & -use monthly wall assistant) bill paying calendar to note bill/tax -cell phone due dates -wrist watch

Personal Wants, Needs, and Safety Assessment Form (Bourgeois, 2006)

Wants & Needs Assessing the Wants, Needs, Safety of: Margaret Jones (name) Environment: Home Hospital Assisted Living Nursing Home (circle one) y The expression of personal preferences, likes and Wants: The expression of personal preferences, likes and dislikes dislikes Likes: Dislikes: Toast & black coffee for Breakfast Bright light (keep blinds semi-drawn) y The satisfaction of hunger, thirst, physical comforts, Bath in the evening before bed Broccoli, rutabaga, slimy foods, emotional needs Books, stuffed animals, a favorite peppermint shawl Large, group activities y Pain, Emotions Classical music; she played the Frank, a former neighbor who was violin. mean to her dog. y Safety: At home, falls prevention, medications, Prefers to be alone in her room. emergencies, in the hospital, safe eating/swallowing, Needs: The satisfaction of physical comforts and emotional needs personal hygiene Physical: 3-hour toilet schedule; Emotional: needs minimal assistance except for Likes to be touched on hands, hugged supervised ambulation Family pictures and her bible are Pain: Recovering from hip fracture comforting (5/7/06) Likes animals Pain levels range from 5-7 on a good day

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I feel sick. I press button for help Engagement & Activities y Early Stage Dementia y Successful use of Planners and calendars to maintain desired activities y Middle Stage Dementia y Successful engagement or participation with I change my clothes every day. y Activity reminders y Enhanced stimulus characteristics y Late Stage y Successful engagement with Activity modifications

Problem Behaviors y Repetitive Questions y Fears and Anxieties y Agitation y Solutions: y Memory Book page y Fake letters y Reminder Cards My jobs: Dusting y Memo Board Fold the laundry Iron the clothes Sweep the kitchen

Functional Goals Functional Goals: Early Stage Dementia y Expressive Language: Conversation, Wants/Needs y Receptive Language: Comprehension of y Client will describe current week’s events using conversation, questions, reading, daily planner providing 4 items understanding cues (auditory, visual, tactile) y Client will describe 4 future scheduled events y Cognition: Memory using daily planner y Long term: naming, orientation y Client will describe how to drive to desired y Short term: reduce repetitive questions locations using driving notebook y Procedural: sequencing y Client will explain how to retrieve email from his y Level and type of cuing/assistance? computer using written cues y Criterion for mastery? y Client will increase pleasure reading to 15 min y Caregiver training goals? per day using large print materials.

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Driving Instructions (to be included in a Personal Identity Card Driving Notebook)

Name: Melissa Browning From Home to Keeping Track of bills and taxes Address: 1234 Ivy Street To Check e-mail on your computer: My City, My State, Zipcode Grocery Store Telephone: (xxx) 123-4567 1. Turn RIGHT at end of driveway. In case of Emergency: 2. Turn LEFT at Stop sign Notify: Harvey Browning, my brother (Shamrock Rd.) 1.Press [power] button. Telephone: (xxx) 234-5678 3. Turn RIGHT at Shannon Lakes 2.Wait until icons appear at the Medical Alert: Allergic to penicillin Rd. My doctor is: Dr. William Smith at St. Mary’s Hospital 4. Turn LEFT at Shopping Center bottom of screen. Telephone: (xxx) 567-8912 Entrance 3.Using the mouse, Move the arrow 5. Park the car. to the Outlook icon. 4.Click the left mouse button. From Grocery Store to 5.Read through the list of mail Weekly Planner Home messages. 1. Drive to Shopping Center 6.Using the mouse, Move the arrow Entrance. 2. Turn RIGHT onto Shannon to the message you want to read. Lakes Rd. 7.Click the left mouse button. 3. Turn LEFT at Stop sign (Shamrock Rd). 8.Read your message. 4. Turn RIGHT at Edenderry Drive. 5. Turn LEFT into home driveway.

Functional Goals: Middle Stages: 1. Client will increase accuracy of yes/no responses using memory book and picture cues. Functional Goals: Later stages 2. Client will decrease daytime napping with increased engagement in structured activities using reading, writing, y Interventions designed to and matching skills y Improve comprehension & cooperation 3. Client and caregivers will use Memory book and Written y Increase memory retrieval & conversation choice for conversation y Maintain safety 4. Client will use words, symbols, gestures to say “Thank y Maintain socialization & preferred activities you” and “I love you.” y Decrease agitation My wife is Linda. y Maintain self feeding, dressing, bathing y Decrease frequency of aberrant or disruptive behaviors

I love you! ♥

Document change in cognitive‐communication Examples of specific communication behaviors function as a result of therapy y Remembering a caregiver’s name y Language produced and/or comprehended y Conversing at meal times, with family & friends y Requesting preferred objects & activities y Ability to express needs, satisfaction, pain y Stating needs, level of pain & discomfort y Greater language output during social activity than y Sharing feelings with caregiver & friends during non‐social activities y Reading aloud (for socialization, to choose menu y Frequency of agitation or disruptive behaviors items, etc.) y Amount of assistance needed during ADL y Participating in preferred activities y Expressing satisfaction, happiness

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Designing Activities as Intervention High Stage Level Activity: y Goal: To improve functional communication for basic and social needs, the patient will produce 3 statements about personally relevant topics (therapies provided by physical therapists) with minimal assistance with 80% accuracy per 15 min session. y This goal could be modified by increasing the number of statements when mastered at 5 and 8, related to the topic when provided with visual stimuli [therapy photographs, partial written prompts] and auditory cues [i.e., minimal prompts Bourgeois, M. (2001). Matching activity modifications to the progression of functional changes. In E. to encourage conversation and matching activity]. Eisner, “Can Do” Communication and Activity for Adults with Alzheimer’s Disease: Strength‐based Assessment and Activities (pg.101‐107). Austin, TX: Pro‐Ed.

Activity: The client will match the name of the therapy to the identifying picture and state personal information about the type of Middle Stage Level Activity therapy. If the client needs assistance there are partial word cues to use. y Goal: To increase communication regarding personally relevant information (names of major muscles), the client will match muscle names to their location in the body with minimal assistance (visual cues: word bank and physical body cues from speech‐pathologist) with 50% accuracy during 3 out of 5 opportunities per 15 minute conversation. y This can be modified with mastery to 60‐75‐80% accuracy during 4‐5 opportunities.

Activity: The client will match the muscles to the correct location on the body. Late Stage Level Activity: y Goal: To maintain interests, increase communication of social needs, and increase engagement with personally relevant materials (which is improved quality of life), the client will correctly match personally relevant stimuli (pictures of different therapies done by physical therapists), with moderate assistance (written prompts) with 50% accuracy during 2 out of 3 opportunities. y This can be modified with mastery to 60‐75‐80% accuracy during 4‐5 opportunities.

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Activity: The client will match therapy pictures to each other. Clinician could put the name of the therapy underneath the 1st Illustrative Case #1: Dementia one to give assistance to the client. y V.S. (86 yrs., B.S. degree) Caregiver identified problem y Lives in Assisted Living Facility behaviors: y Assessment: July, 2000 1. Client experiences difficulty y MMSE: 22/30; mild dementia remembering names daily y Boston Naming Test: 9/15 2. Client has difficulty initiating y WRAT 3: 52/57 conversation daily y Oral Reading: 24/24 large print 3. Client cannot recall room y Expressive Language number daily Conversation: rating = 5/6 4. Client experiences trouble y SR Screen: passed when transferring to wheelchair daily

Examples of Functional Goals Case # 2 M.H. (84 yrs., B.S.) 1. Client will refer to memory book to initiate conversation Diagnosis: Progressive , Balance Disorder a. with clinician 8/10 times within 30 minute treatment session for 2 consecutive days Assessment: July, 2000; Assisted Living Facility b. with peers 6/8 times over 4 consecutive treatment days with minimal assist (clinician points to book) MMSE: 24/30 WRAT 3: 39/57 Boston Naming Test: 11/15 2. Client will address people by name by reading name tag SR Screen: passed a. with clinician; upon initial contact without prompts b. with peers; upon initial contact with minimal prompts (pointing) Expressive Language Conversation: rating = 5/6 3. Client will remember room number a. with clinician; client will respond with 90% accuracy to prompt, “what Oral Reading: 24/24 small print is your room number?” Caregiver identified problem behaviors: b. client will reduce questions about room number to staff to

Getting Nursing Assistants to Cooperate Goals: Development of Training materials Interactive CD‐ROM, VHS, and Web‐based training programs for nursing aides 1. Client will use her memory book to initiate conversation Strategies for Dementia 2. Client will read the card and follow safe swallowing 1. Dementia Overview Strategies for managing strategies 2. Speaking Skills Residents with Aggressive 3. Redirecting Skills Behavior 4. Communication Cards Solving Problems Strategies for managing Residents with Psychiatric 1. What’s the Problem? Problems 2. What’s the Solution? 3. Client will recall clinician’s name 3. Preventing Problems When Bad Things Happen 4. Client will remember to ask or call her caregiver when 1. When Bad Things are Said: Racist Comments she wants to get up 2. When Bad Things are Said: Sexual Talk 3. When Bad Things are Said: Insults 4. When a Resident Dies

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Evaluation of Training Materials y Irvine, A. B., Bourgeois, M., & Ary, D. V. (2003). An interactive multi‐ media program to train professional caregivers. Journal of Applied www.orcasinc.com Gerontology, 22, 269‐288. y Irvine, A. B., Bourgeois, M. S., Billow, M., & Seeley, J. (2007). Web Training for CNAs to Prevent Resident Aggression. JAMDA, www.hcimarketplace.com October, 519‐526. y Irvine, A. B., Billow, M., Gates, D., Fitzwater, E., Seeley, J. R., & Bourgeois, M. (2011). Internet Training to Respond to Aggressive Resident Behaviors. The Gerontologist, 52, 13‐23. y Irvine, B., Billow, M., Gates, D., Fitzwater, E., Seeley, J., & Bourgeois, M. (2011). An internet training to reduce assaults in long‐term care. Geriatric Nursing, 33, 28‐40. y Irvine, A. B., Billow, M., Eberhage, M., Seeley, J., McMahon, E., & Bourgeois, M. (2012). Mental illness training for licensed staff in long‐term care. Issues in Nursing, 33, 181‐194. y Irvine, A. B., Billow, M., Bourgeois, M., & Seeley, J. (2012). Mental illness training for long term care staff. JAMDA, 13, 81.e7‐81.e13.

…and the research continues Final thoughts…. y to document the effects of written and graphic cues in Individuals with dementia can a variety of settings y learn new information y to explore new ways to support and maintain personal y re‐learn previously known but forgotten information interests and identity and behaviors y to develop caregiver training materials that enhance y using interventions that reduce demands on impaired quality of life of both the person with dementia and cognitive abilities and capitalize on spared ones their caregivers Clinicians can be reimbursed for y Direct client intervention y Caregiver training

Zeisel & Camp, 2009

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