A Collaboration between TR and SLP: Engaging Patients with Advanced Dementia in Activities that Stimulate Social Communication

Transcription

1 A Collaboration between TR and SLP: Engaging Patients with Advanced Dementia in Activities that Stimulate Social Communication

2 Introductions Willie Si, Recreation Therapist, R/TRO Honours BA in Therapeutic Recreation, University of Waterloo Danielle Coughlin, Recreation Therapist, R/TRO Honours BA in Therapeutic Recreation, University of Waterloo Erin Yeates, Speech-Language Pathologist MHSc in Speech-Language Pathology, University of Toronto

3 Agenda 1. Geriatric Psychiatry Service 2. Role of TR, SLP with key concepts 3. Dementia s effects on communication and leisure 4. Communication challenges non-verbal, language barrier, disruptive vocalization 5. Strategies to improve communication 6. TR & SLP Collaboration World Travelers Club Creative Storytelling Group 7. Interactive exercise 8. Q&A

4 Geriatric Psychiatry Service 20 bed inpatient assessment unit; 65yrs+ Dementia + responsive behaviours LOS: 4-7 weeks IP collaboration

5 Therapeutic Recreation What is Therapeutic Recreation? TR Role: Assessment Plan Implement Evaluate Discharge planning

6 Strengths-based Approach Patients current strengths and abilities Not deficit based, not trying to fix a problem Understanding environmental factors and resources is crucial We need to change and adapt, not them (Anderson & Heyne, 2013)

7 Speech-Language Pathology Communication: Assess to determine current communication abilities (receptive and expressive language, including reading and writing) Liaise with team to develop strategies to maximize residual communication abilities Individuals are not always able to follow instructions or maintain attention for objective or formalized testing Swallowing: Swallowing difficulties are not generally seen until later stages in the disease Common difficulties include drooling, weight loss, food refusal, pocketing, coughing or choking Multifactorial: related to environmental distractions, cognitive and physical/neurological changes

8 Communication Communication is the exchange of information between individuals Verbal: expressive vs. receptive language Non-verbal: gesture, facial expression, body language, tone of voice, speed of speaking, eye contact Communication skills are essential to establish relationships in care environments, enable people with dementia to engage in positive social activities, optimize residual memory and communication ability, and reduce the impact on disturbed behaviour (DeVries, 2013).

9 Communication Deficits and Effect on Leisure Involvement Comprehension Instructions, guidelines, tasks, purpose, Ability to contribute Feeling socially isolated, loss of sense of identity, feeling of embarrassment Disruption to group cohesion & flow of group Varying cognitive abilities

10 The Communication World of the Individual with Dementia Changes Cognitive Changes Sensory Changes Examples Aphasia, memory deficits, visuospatial deficits, visual hallucinations, disorientation, apraxia Hearing and vision loss Emotional and Functional Impact Loss of confidence, emotional lability (or lack of affect), irritability, misperceptions, miscommunications, disinhibition, self-stimulatory behaviour, decreased self-esteen, exhaustion, depression, decreased participation

11 Expression Early AD (1-3 years) Middle AD (4-10 yrs) Late AD (8-12 years) Fluent, grammatical Tangential Empty words Reduced content Naming errors, word finding difficulty Logorrhea Spelling errors Slower, halting Content further reduced WFD repetitious Meaningful output greatly reduced Echolalia, jargon Mutism Incoherent Inability to write Automatics ok Comprehension Reading is intact (but forgotten) Missing the point Difficulty with idioms, metaphors, lengthy/complex info Still ok at the word/phrase level literal One-step instrux Difficulty with group conversation Difficulty even with single words Can read single words but not understand Contextual words and phrases Nonverbal Largely intact Disinhibited Aware of own deficits Still pretty good Less self aware Impaired pragmatics Most will retain social communication abilities to some degree

12 Adapting TR Activities for Patients with Communication Deficits Reading (short stories, recipes, prayers, magazines, etc.) Glasses, education, large font, black on yellow paper, text on 1 side, finger tracing, reading along Word Games (trivia, scrabble, crosswords, word searches, etc.) Changing the rules, limit choices, completing last word, Discussion/conversation (reminiscing, memory album, creative story telling, world travelers club, etc.) Accuracy and content not important

13 The quick brown fox jumps over the lazy dog!

14 The quick brown fox jumps over the lazy dog!

15 Communication Challenges Specific to this Population 3 Common Issues: Non-verbal Language Barriers Disruptive vocalizations

16 Engaging patients who are non-verbal Activities: Music Snoezelen Hand massage Strolling around unit Use of nonverbal communication strategies to engage the person and allow them to feel like they are part of the group even if they can t contribute verbally

17 Language Barriers and Dementia Anecdotally, it is often noted that people in the later stages of dementia tend to favour their mother tongue that doesn t mean that this first language is intact Even in normally aging seniors, the ability to maintain fluency in more than one language declines this is exacerbated in dementia No matter the age of acquisition, educational level, frequency of use and baseline fluency, seniors with dementia tended to retreat to their native language (Mendez et al,1999) This is in contrast to people with aphasia related to stroke, who tend to lose and regain both languages synergistically

18 Overcoming Language Barriers Non-verbal cues Key words Technology Mirroring expressions and tone positive reassurance Rephrasing and giving extra time to process information

19 Disruptive Vocalization Disruptive vocalization consists of excessively loud and/or repetitive verbal utterances, such as single words or phrases, nonsensical sounds, screaming, moaning and constant requests for attention (Sloane et al., 1997). Contributing factors: Too much sensory stimulation Not enough sensory stimulation Confusion, delirium Pain, discomfort Fatigue Patterns & Triggers During meal During care Sundowning Noisy environment (Buettner & Kolanowski, 2003)

20 Managing Disruptive Vocalization Try treating pharmacologically anxiety depression delirium pain Implement behavioural strategies: Providing sensory stimulation (i.e., therapy doll, pet therapy, rocking chairs, familiar music, snoezelen environment, gentle massage, etc.) Minimizing unwanted sensory stimulation Optimizing vision and hearing where possible (Buettner & Kolanowski, 2003)

21 Communication Strategies for staff, family members Study: Educating Nursing Assistants to Communicate More Effectively with Nursing Home Residents with Dementia Findings: in behavioural issues, in depression symptoms, irritability, disorientation, staff retention rates (McCallion, Toseland, Lacey & Banks, 1999)

22 Communication: What Doesn t Work Quizzing: e.g. Who am I? Elderspeak Reorienting to your reality Correcting Ignoring Attempting to engage in rational conversation (McCallion, Toseland, Lacey & Banks, 1999)

23 Communication Strategies Non Verbal Sit face to face. Establish eye contact. Use gestures to help explain instructions. Use a calm, friendly tone of voice. Use instrumental touch to support or guide the person through tasks. Body language and physical contact may become more important. Keep distractions to a minimum. Give the patient time to respond. Move slowly. Approach the patient from the front. Maximizing Comprehension Maximizing Expression Avoid overly complex sentences Address the patient by name Try repeating, then rephrasing Break down a task into simple steps Speak clearly and slowly...but not TOO slow Avoid slang, idioms and nuances. Keep choices simple limit to two or three options Don t disagree with stories or statements that are untrue. Encourage the person to communicate however they can. Don t guess at a word they can t get. Listen for meaningful words and ideas. Keep talking about things that were important to him family, friends, and places. Show him pictures of these memories.

24 TR and SLP Collaboration Why collaborate? Development of 2 groups Strength-based approach to engaging in groups

25 Benefits of Group Therapy Group therapy can help the participants with dementia build closer relationships than they could build on their own -- cultivating opportunities for people with dementia to communicate with each other fills a basic social need, and also can increase feelings of satisfaction, how much people eat, and verbal communication. (Kelley, 1997)

26 World Traveler s Club Origin of the group: varied backgrounds, opportunities created by learning about already familiar cultures and new cultures Multi-sensory: visual, auditory, taste, olfactory Goals and process

27 Creative Storytelling Group Origin of the group Program protocol Choosing appropriate photos: upsetting photos, high resolution photos, black & white is good, avoid famous people

28 Riding for Pleasure to Attract the Ladies

29 Let s Write a Story!

30 References Anderson, L. S., & Heyne, L. A. (2013). A strengths approach to assessment in therapeutic recreation. Therapeutic Recreation Journal, 47(2), American Speech-Language-Hearing Association. (2005). The roles of speech-language pathologists working with individuals with dementia-based communication disorders: technical report [Technical Report]. Available from Bayles, K. A. & C. K. Tomoeda. (2007). Cognitive-Communication Disorders of Dementia. Plural Publishing, Inc. Buettner, L. & Kolanowski, A. (2003). Practice Guidelines for Recreation Therapy in the Care of People with Dementia. Geriatric Nursing. 24(1), De Vries, K. (2013). Communicating with older people with dementia. Nursing Older People, 25, (4), Kelley, M. (1997). Social interaction among people with dementia. Journal of Gerontological Nursing; Apr 1997; 23, 4; 16. Liddle, J., Smith-Conway, E., Baker, R., Angwin, A., Gallois, C., Copland, D., Pachana, N., Humphreys, M., Byrne, G., & Chenery, H. (2012). Memory and communication support strategies in dementia: Effect of a training program for informal caregivers. International Psychogeriatrics 24:12, McCallion, P., Toseland, R. W., Lacey, D., & Banks, S. (1999). Educating nursing home assistants to communicate more effectively with nursing home residents with dementia.the Gerontologist, 39(5),

31 References (cont) Mendez, M. F., Perryman, K.M., Ponton, M.O. & J.L. Cummings Bilingualism and Dementia. The Journal of Neuropsychiatry and Clinical Neurosciences, 11, Sloane, Davidson, Buckwalter, Lindsey, Ayers, Lenker, Burgio (1997) Management of the patient with disruptive vocalization. The Gerontologist, 37(5), x Stokes, G. (2012). Words can mask meanings in dementia: listen to understand. Nursing Times, Nov 13-19, 2012, 108 (46), 7. Williams, K., Herman, R., & Wilson, K. (2009). Elderspeak communication: Impact on dementia care. American Journal of Alzheimer's Disease and other dementias, 24(1),