Cognitive Stimulation in Dementia

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[0:00] Music

Speaker0:
[0:15] Hi, everyone. I'm Emily.

Speaker1:
[0:17] And this is Eva.

Speaker0:
[0:18] And you're listening to Speech Talk.

Speaker1:
[0:20] We're your research-based book club so you can do evidence-based practice in practice.

Speaker0:
[0:25] So let's start talking. So this week, we are talking about general cog interventions with our dementia population. And it's just such rough waters, man. I feel like everyone and their brother in the therapy world is like, why can't you pick them up? They don't understand me. Or I can't understand them. They're not following directions. They're not doing X, Y, Z. And I just cry inside.

Speaker1:
[0:49] They're not doing a lot of things.

Speaker0:
[0:52] I'm just, yeah, they're doing a lot of things that aren't productive for anything other therapies want to do. But I just start crying because it's like, we're not going to make, like, I just feel like we're not going to make any progress. And I'm just so reluctant to pick someone up for following directions or, I don't know, remembering parts of the building. Any new learning. So I wanted to pull out this research and give everyone a leg to stand on. So when we get the inevitable, but they need you because they're confused, we can talk about it.

Speaker1:
[1:28] Yeah. And some of those things you mentioned, like wayfinding in the building, like orientation, they are so like up to the individual. Some people have capacity for it, despite having fairly advanced dementia. And some people don't. don't, they don't recognize that their blanket isn't food. And like, we really got to suss that out like at a patient to patient level, like not stimulable for directions or new learning is really patient dependent. So we wanted to be looking at what are some of the, what does research say about the effectiveness of different cognitive therapies for our dementia folks? And to do that, we looked at an article called, let's see if I can do it in one breath, Do Cognitive Interventions Improve General Cognition in Dementia, a Meta-Analysis and Meta-Regression? Written by J.D. Huntley, R.L. Gould, K. Liu, M. Smith, and R.J. Howard. Boom! Did it. And as a quick preface, we really hated reading this research article.

Speaker0:
[2:32] Loathed it.

Speaker1:
[2:34] We've never seen so many phrasal repetitions, acronyms. We kept being like, what was the C-T-M-R-D-what?

Speaker0:
[2:44] J.D., I am coming for you after this.

Speaker1:
[2:48] It was one of the hardest articles we've read, and we thought we were kind of getting good at this.

Speaker0:
[2:53] No. This was really like just a humbling article to read. It was like, we're doing this for other people. And it's like, dang it.

Speaker1:
[3:02] Like, how much do we want to help? I don't know. Maybe we bail. So this article's general aim was to evaluate the efficacy of cognitive interventions on improving general cognition in dementia. And as clinicians, this can help us look into which strategies to use with our dementia patients. Yes. How did they do this?

Speaker0:
[3:21] So they looked at studies that had randomized controlled trials and participants with the mean age of 60 or higher. The studies looked at, they used either the MMSE, the mini-mental, or the ADAS-COG to evaluate cognitive changes. Yeah.

Speaker1:
[3:40] And in the studies they gathered, they kind of generalized four types of cognitive interventions. The first one is cognitive therapy, or CT, which is a repeated practice of standardized, very specific tasks with an assumption or basically a hope it will generalize to other things. What did they look at next?

Speaker0:
[4:03] They looked at cognitive stimulation next. So this one was more naturalistic. Social activity is more in group settings with multiple cognitive domains. So they looked at reminiscent treatment, reality reorientation, those kind of things.

Speaker1:
[4:19] Yeah, and then the final main group was cognitive rehabilitation, or CR. This was a person-centered approach with a particular aim at improving everyday ADL functions. And then they had mixed or just a combination of techniques. And the specific treatments for each of these categories were not listed. So unhelpful. Putting that out there. Unhelpful.

Speaker0:
[4:46] We are coming for you, JD. So, what did they find? So, CS, the cognitive stimulation, they showed that it was beneficial. Improved general cognitive outcomes as seen through those MMSE and the ADOS COG scores. They also showed that both CT and mixed therapies do.

Speaker1:
[5:07] Not show the same level of improvements.

Speaker0:
[5:09] They don't show the same level of improvements.

Speaker1:
[5:12] Yeah. So CS, good. CT, mixed therapy, bad.

Speaker1:
[5:17] And then here's the annoying part. They were like, maybe none of this matters. And I quote, cognitive interventions remain of debatable clinical significance. So yeah, that was a really fun like wrap up sentence to read after we had just trudged through some of the most dense research we've looked at yet. But they did point out that clinical significance is like, is this applicable in a clinical setting? Statistical significance is what showed that, like, yes, the MMSE and ADAS COG scores showed CS treatment to be effective. What they pointed out, though, is that these scores, MMSE and ADESC-OG, do not look at quality of life or functional improvement, mood, and carer attitudes. And yes, they wrote carer. Maybe that's caregivers. Maybe that's how much our patient cares. We don't know.

Speaker0:
[6:18] Oh, that was a good one.

Speaker1:
[6:20] Yeah. But they did say that, look, if we're going to be overall trying to understand the effectiveness or usefulness of these therapies, we should be looking at those categories. We know that some things you can do on like a standardized test, but then in a naturalistic setting for like more of an ADL activity, our patients are completely out to sea. They're like, oh, I can repeat to you five numbers in a row. And you're like, okay, what was your medical record number? And they're like, oh, I don't know.

Speaker0:
[6:53] I was supposed to remember that.

Speaker1:
[6:55] Yeah. What are we talking about? So there's some difference in terms of how we evaluate it.

Speaker0:
[7:02] The research also said that cognitive research in general tends to be a difficult area to examine clinically because it deserves the same rigor as pharmaceutical trials on the effectiveness it poses. And it poses very different research obstacles, right? So they talk about how easy it is in like a pharmaceutical study to give a placebo treatment. And in these therapeutic type studies, that's much harder to give or to not give a treatment and still keep the engagement and follow up evaluations.

Speaker1:
[7:32] Yeah. A therapeutic placebo is kind of a hard thing to pull off because a lot of times it's just interacting with people and like giving them stimulation is helpful. So your like control group is still getting some type of engagement a lot of the time. And if you just wanted to run the trial against people who are not participating in a in the like a target therapeutic technique, they still are probably receiving stuff on the side, like social support, family engagement, probably taking pharmaceuticals. Like it's, you can't tell them to stop doing those things for the sake of research. So yeah, it's a pretty tough one to try to figure out how to do.

Speaker0:
[8:16] Right. So, and then this article in a article in a nutshell. So the study showed improvement in testing measures, but there is really no significant evidence of change and meaningful qualities of life.

Speaker1:
[8:28] So did it matter? Did it matter? That's the big question.

Speaker0:
[8:31] That is the only question.

Speaker1:
[8:34] And while people being able to do the MMSE better, I don't think matters long run. I think there's some useful pieces of information here. So how are we going to apply this research? We are not the only people who do cognitive stimulation. We are part of teams. Activities departments do a lot to help make sure we are maintaining cognitive levels, decreasing rates of depression. How can we be engaging with our activity directors and activity aides?

Speaker0:
[9:05] Right. Like, do your aides and your directors understand cognitive levels and the best way to approach different people with dementia? Not all one size fits all like not everybody can just go to bingo and and play like they need some one-to-one support like are their activities geared toward higher level individuals is there some sort of scaffolding in place or um a change to the activities to be inclusive of all of our dementia abilities and interests and.

Speaker1:
[9:38] To the point of like dementia is a very broad-ranging. We have people who have these very early-onset dementia difficulties, and then we have people who have no verbal response at all. So sometimes just being in the activities room where folks can keep an eye on them, that they're getting some social engagement, people are saying hello to them. Even if they can't do the task, being included is important for them in quality of life. Getting back to that issue of what is like a clinical approach versus just a quality of life thing.

Speaker0:
[10:13] Yeah.

Speaker1:
[10:14] Sending someone to bingo is not necessarily a good clinical activity, but it can be a great way to just making sure somebody gets to interact with other humans instead of getting left in their room.

Speaker0:
[10:27] Yeah. And yeah, bingo is a fun higher level activity because you're now you're paying attention you're doing these things but, I mean, somebody can still move pieces. They can sort the bingo chips, like with the activities director, or they can.

Speaker1:
[10:44] Or they could be the person to read the numbers, like if they still have functional reading, being like, and Jennifer gets to sit up here at like the seat of honor and read out the bingo numbers today.

Speaker0:
[10:55] Oh, I love that. The seat of honor. That's cute.

Speaker1:
[10:58] But also with like the activities department we've been really trying to strategize good dementia activities and we have like all these cards and envelopes that's like a very easy task for somebody to do is just like putting cards in envelopes or during the holidays getting the decorations out of the boxes okay we're just unpacking this um then making sure to your point of like scaffold activities, what are simple, oftentimes manual activities that have a very low cognitive demand that they can participate in because that's important participation.

Speaker0:
[11:35] And I love that example of just like taking items out of boxes or just because that is such a helpful task, right? And you don't think about that as like a cognitive task, but you're doing like this repetitive motion. You're still, and it's helping other things too, like you're bending or lifting or you're talking to people like, will you grab me the wreath? Will you grab me the lights or untangling lights? Ooh, that would be, that might be a high level.

Speaker1:
[12:04] That one may take them all afternoon, but they would be occupied.

Speaker0:
[12:09] Occupied.

Speaker1:
[12:11] And as always, we really hope that research makes you feel like you can stand your ground on clinical decisions. So using this article to cite why it's inappropriate to just pick people up for quote direction following. Someone may be stimulable for that. You may find that they are not stimulable for direction following, but they're good with visual cues. You may learn more about them and their communication techniques that you can educate your rehab team or other departments in, but getting them to follow directions may in and of itself not be an appropriate therapeutic Right.

Speaker0:
[12:46] I had, this happened recently where my site had an individual who just kept falling. Like they just kept getting out of their chair or they just kept trying to put themselves back into bed. And they're like, well, Emily, we really need you to pick them up for safety and following directions. This person has been in the facility for, for a while. So it's not like it's new learning anymore at this point. For this particular person, I just did a RIPA. Where are they at cognitively? So they were severely cognitively impaired. So there's no more new learning. But in general, when I ask them safety questions, they're like, so what do you do if you want to get into your chair? They're like, well, I have to call a nurse. Why don't you call a nurse? I don't like to ask people for help. So it's like, I can't change.

Speaker0:
[13:43] They're like, I can't change. Like they understand like general safety enough that they know that like, if you need help doing something, you should ask for help. But then they're not asking for help because they have this like latent pride from whenever they were just like normal and able to do all this stuff. It's like, I, I can't, I, I can't teach something he already knows, He knows to pull a call. He knows to say this is not safe, but he's too prideful. He doesn't want to. And his dementia is telling him that he's strong enough to just move his butt from the bed to the chair or go to bed because he's that forgetful. But there's no real changes that you can make in that particular case. So doing an eval only.

Speaker1:
[14:29] Yeah, eval only. And we're going to touch on that later. But I had a patient very similarly recently who like, all right, safety and precautions. She had come in, sepsis, bad, like worsening AMS and lots of pressure ulcers. And I was like, all right, let's talk about like getting up, making sure we're doing education on mobility safety, how to do prevention for pressure ulcers. And she could answer the questions perfectly every time. And I was like, okay, so what are you going to do today to help Make sure that you're addressing these needs of getting off of your back so that you don't continue to develop wounds. She was like, I'm going to get up. I'm going to walk to the bathroom. I'm going to go to activities. And I was like, okay. Right. When was the last time you walked? And she was like this morning i'm like nope no you haven't walked since you've come into this building and every time we're working with you with physical and occupational therapy you don't want to sit at the edge of bed and you don't want to stand up so like how can we support you to like get up so that you don't continue to have these terrible pressure ulcers she's like but i can do it and i was like yeah and we had that conversation so many times she could answer all the safety questions and then would not engage in therapeutic activities to like improve the situation because she was like, I can already do that. So yeah, definitely had to just write that discharge eventually.

Speaker0:
[15:59] On that point too, like I'll have a lot of people who are like very good at verbal problem solving. So how do you do this? How do you sequence these activities? What are the steps? And then I'm talking to my OT and they're like, no, this, this is a nasty man. Like he's not doing all these steps that he says he can do so he can sequence all the bathroom steps he seems verbally very confident in these adl activities but by god that is nasty man.

Speaker1:
[16:33] Yeah. So anyways, the theory versus the practice, not always the same thing.

Speaker1:
[16:40] And just kind of like going back to how this research helps us, we should be making sure that our treatments are meaningful and impactful and making changes for our clients. And that means that we need to be realistic about what therapy can provide. I've recently had a patient that I've been doing errorless learning with where you kind of go in and you're like, hey, this is where this thing is. Do you know where it is? It's in this place. So you don't let them kind of flounder and guess. And she has a very hard time with consistent carry over like she can direction follow in the moment but then completely loses track of where she is what she's doing there's very low attention and follow through but we've been working on this just like over and over again and one of the issues is she's a wanderer risk and has just been eating stuff like her roommate's hair cream and her roommate's snacks and instant coffee And it's one of those things where you're like, okay, I'm not going to be able to get you home independent, but we can try to use cognitive strategies to minimize these things that are happening in the building.

Speaker1:
[17:55] And uh so i made her a snack drawer so she would stop wandering to find foods and in our sessions she was finding it and then the other day i came in and i was like how do i see if she's able to do this on her own do i just kind of like show up in her room and see if she's eating throughout the day i opened the top drawer where i had put her snacks and there was like a bunch of half-eaten snacks which i had to throw away but i was like oh she's finding them yeah god knows how long this pudding has been open, but she found the pudding on her own. I'm so proud of her. So again, to the point of what we are looking at in terms of showing improvement in our patients' lives with cognitive therapy, I don't think I'm ever going to be able to get this patient to follow a set of printed directions from their doctor or do their own med management. But through repetition and like a highly structured task that we are targeting in as naturalistic a way as possible. This lady is feeding herself out of her own snack drawer. Oh, I love that. So small successes.

Speaker0:
[19:03] I love that. Going back to the article, they talked a lot about grouping being that most effective strategy. Some of the people that we are getting into the facility aren't necessarily appropriate for groups for insurance reasons, right? Like anybody who's skilled med A is typically not allowed to be grouped in Ohio.

Speaker1:
[19:28] Or they're bed bound. I love it when I would use to get like put this person in a group. I'm like, yeah, I can't get them out of their bed. So no.

Speaker0:
[19:37] Yeah. Yeah. What are you supposed to do? Bring a bunch of other people into their room to group them? Like what is, no. I also, one of the places that I work, they had people like physically separated by dementia level. And they were like, okay, well, that's when I was still trying out things. And I was like, maybe I'll try and group them. And just physically bringing everybody to like one solid location was even with them all being mobile, but like just getting them into one location was hard. But those B people, they can sometimes be grouped, but it's still only half of, not even half, 25% of their minutes, their percentage of minutes is allowed to be grouped. So that means 75% of your other treatments have to be individual. And you have to make sure that those carryover of skills are happening in the group. So if your goals really are to just have them in a group, grouping them is not always easy or something that you're able to complete.

Speaker1:
[20:43] And to always make sure that we're being specific with what we're doing in therapy. If what you assess is that, hey, you get a patient. They're like, this person has dementia. See them. You're a speech therapist. One, having the confidence to say, that's not necessarily appropriate. But two, saying, look, this person is... Experiencing a lot of communication breakdowns in the form of like, they're yelling a lot, they're wandering, and they seem very agitated. Let's see if we can like, chill them out so that they're safer within the facility. That's a valid thing to do. But a lot of that is probably going to be more like bringing things back to activities, training CNAs and unit nurses on how to keep them safe and how to keep their needs met despite difficulties with communications, it's not looking like sitting down and doing workbook tasks. You know, so making sure that if you are picking up people with dementia, you have a good idea of what your end game is, because you could just do therapy with them indefinitely and be like, progress is slow due to guess what? Dementia.

Speaker0:
[21:51] So sometimes it is okay. Like if you're, if you're expecting limited or no beneficial differences in cognitive therapy, it's totally okay to do an eval only. So sometimes you're getting someone who has a diagnosis of unspecified dementia. So in those cases, you can help your doctors to specify that dementia. Completing a RIPA 2 and have that skilled evaluation of the dementia levels, especially if that person is a moderate to severe dementia. They're potentially not appropriate for cognitive-only treatment. Eva has highlighted so many great ways that you can address those folks, and it's very personalized. But sometimes it's just not for you, or you don't have the... What people are looking for is really not appropriate, and just providing that education. I can't fix X, Y, Z per my Eva.

Speaker1:
[22:51] Yeah. And like we had a woman who is like pretty much not stimulable for anything. The most you could do is just kind of set her up with something at her table. Like, sorry, at a table at activities so that she's, you know, around people and that she's kind of generally monitored. Then she was on isolation they're like what are you gonna do with her and I was like not not a whole lot I'll go get those like baseline numbers for you and like help inform her overall case history on what her current level of impairment is but She can't speak. She can't follow directions. She is now isolated in a room. The main thing I would recommend is that she is in a space where like if she is trying to get up out of her wheelchair, which she does try to do, and she did fall and she did get a big old knot, that we're being able to work as a team to help keep her safe. But if she is being kept in her room by herself and she's not trying to get out of her room, there's really nothing I can do. So look at the eval.

Speaker0:
[23:55] And yeah, some of that, it really is just a lot of caregiver training. Like you said, you have to make sure your CNAs know what is a good redirection for that person. So actionable items. Try and keep this article handy when you are challenged and to stay up to date.

Speaker1:
[24:15] Yeah, make sure they try and read this article and then let that buy you a lot of time.

Speaker0:
[24:24] Oh my gosh you can cry you could cry with us because it was it's a hard one not a terrible article because it does give a lot of information they did a lot of work but it's just the way it was written man it.

Speaker1:
[24:35] Was hard um and remember just because someone who's cognitively impaired does not mean they're therapy appropriate

Speaker0:
[24:41] It also doesn't mean they're not it doesn't mean they're totally not. Eva has, Eva has shown me some light today of all her very inventive therapeutic techniques.

Speaker1:
[24:53] I've been reading a dementia textbook on the side. So I'm a free time getting

Speaker1:
[24:59] up to really exciting things like reading a dementia textbook. Anyways, just remember, be specific about what your expectations and goals are with your dementia patients so that you can treat them appropriately. And if you decide that further cognitive therapy is not appropriate, just let that go. Just, just hit that discharge. Don't pick up that, that person after eval. Those are all valid options.

Speaker0:
[25:23] Thank you so much for listening. This is a tough one. We hope you enjoyed it. We did it for you.

Speaker1:
[25:29] We always do it for you.

Speaker0:
[25:31] As always.

Speaker1:
[25:31] And we do it to hang out.

Speaker0:
[25:33] And that too.

Speaker1:
[25:34] Anyways, see you next time.

Speaker0:
[25:36] Thanks for listening guys. You've been listening to Speech Talk.

Speaker1:
[25:40] Thank you, everyone, for coming to listen to our research book club.

Speaker1:
[25:43] Until next time, keep learning and leading with research.

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Speaker1:
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Speaker0:
[26:12] If you want even more speech talk content, check out our website at speech talk pod dot com, where you can find all of our resources we made for you, copies of articles covered and Eva's blog following these topics and more.

Speaker1:
[26:24] We're your hosts, Eva Johnson and Emily Brady.

Speaker0:
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