It can be a challenge to find a fun, interesting word game that is targeted to adults and also does not take up more time than is allotted for therapy. In my house, a good game of Scrabble can last all evening, and in most of our therapy sessions we have to address a number of therapy goals in under an hour. That is why I particularly love games that can end within a therapy session, or games that can be left with the patient to continue.
One of my co-workers brought in Appletters, a letter tile game that has several variations. While it is a game designed so that even early readers can play, it is appropriate for adults and has several more challenging options. The goal of the game is to make words based on other player's words until a player runs out of tiles. I like the fact that words can be simple, and there are no points to keep each round. Besides building word retrieval skills, it also helps with concentration, memory and turn-taking. I allow some patients to have a dictionary handy for help. Of course, you could always use your Scrabble tiles without the Scrabble board and play a similar game.
A longer and more complicated game is Rummikub, which is a tile game based on the card game rummy that incorporates some elements of mahjong, two games that many older adults are familiar with. I was taught this game by a patient of mine, and it is definitely appropriate for high level patients who are working on cognitive tasks such as memory, concentration, problem solving, sequencing and executive function. It really does involve a great deal of concentration and takes some time to learn the rules. Depending on the patient's abilities, I have played and finished a game during therapy, but other times I have found another resident to take over my tiles and finish the game if the session is ending before the game is over. If time is a concern, then it is possible to enlist another resident, teach how the game is played, and assist your patient with a few rounds, before leaving the two residents to finish the game together. It is always interesting to see how the two patients are able to finish the game, and if your patient can continue the game without your help. It also fosters social interaction and conversational skills.
Fiberoptic endoscopic evaluation of swallow, or FEES, is a good alternative to the modified barium swallow study, or MBSS, in the long-term care setting for many reasons. In the past year, the rehabilitation company I work for has contracted with another company to provide FEES at our facility. Their speech-language pathologist arrives with her own equipment and food, and I am a part of the entire evaluation.
The benefits are many:
- The patient remains in the facility, which means minimal schedule disruptions and less anxiety for the patient.
- Family, nurses, and other therapists, such as occupational therapists who work with the patient on self-feeding, can observe the study if the patient gives permission.
- The treating SLP and the patient can request specific foods to be tested that the patient might be requesting: cornbread, chips, a hamburger, and so on.
- The evaluating SLP can discuss the patient's swallow function and any deficits as the evaluation is happening.
- The test can be completed during a meal, if that is needed.
- A report is generated before the evaluating therapist leaves, and is available that day for nursing staff to review.
- Dietary modifications can be made immediately.
- The patient can see their own swallowing function and any impairments in real time, which can help the patient to better understand the severity of any swallowing deficits.
Some patients may feel nervous about the procedure. ASHA has a wonderful page that describes the process in layman's terms for the patient and family members here. For more in-depth information on FEES, you might want to read the article from the National Center for Biotechnology Information, which focuses on informed consent, but also describes the process and advantages as well as disadvantages of FEES in detail.
I was pondering what to write about this week, and admittedly procrastinating on Facebook, when I saw a recent post by The Art of Alzheimer's, in which the author wrote about her mother:
"But as much as I enjoy being with Mom, sometimes a fleeting doubt sneaks in.
Should I be doing more? By being her playmate, am I treating her like a child, somehow failing to honor the glorious woman she was?
But one only has to stop and look to see that she is still a glorious woman.
And Mom, it's no sacrifice. It's a joy."
I hear this concern voiced frequently: if Mom or Dad now enjoys "childish" pursuits, such as singing songs and nursery rhymes, playing with stuffed animals, dolls, puzzles and other toys, or otherwise participating in so-called kid stuff, should family members and caregivers join in? Redirect the person to more adult activities? Ignore the person's actions or words as if they aren't really singing "Here Comes Peter Cottontail" at the lunch table? And, yes, I did have a patient who enjoyed an energetic round of "Peter Cottontail."
In skilled nursing facilities, I hear over and over again that it is a matter of dignity NOT to have the patient participate in games or activities that are deemed childish or inappropriate for the patient's age. But if we are using Montesssori-based principles and basing our therapy activities on the patient's needs, interests, cognitive level and daily routine, why would we not include the songs that patient wants to sing and the pictures that patient wants to color?
The difference, to me, is using patient-focused techniques versus demanding that the resident fit the mold of what mature adults "should" be interested in. I have said it before, and I know I will say it again: Let the patient lead the activities.
Does that mean bring in Hello Kitty activity books and superhero puzzles? No.
What it does mean is being aware of what brings a spark to that patient's eyes. Is it dressing a doll? That's a great way to sequence steps and foster conversation. Is it putting together puzzles? There is your problem-solving and attention task. Is it playing Old Maid, Checkers or Go Fish? That can address your goals for receptive/ expressive language, memory, attention, speech and so much more.
Being a good therapist means balancing goals and how to attain them with what the patient needs emotionally and cognitively, and understanding the stages and progression of dementia, so that you can step into their world instead of expecting the patient to stay in ours.
A large part of providing therapy to people with dementia is education. We cannot stop the process, and the behaviors vary greatly according to underlying cause (remember, dementia is a symptom of a disease process, not a disease itself), stage, environmental and social factors, and concomitant diseases, disabilities and disorders.
Are you looking for information for yourself as a clinician and for family members and caregivers regarding dementia? Here are my web picks for dementia, including treatment ideas and inspiration for patients, caregivers, and families.
1. How Mom Learned to Paint. A Facebook page devoted to a daughter's documentation of her mother's paintings and her cognitive decline due to Alzheimer's dementia.
2. Drumming as cognitive therapy. I am reading reading more and more articles about music in general, and drumming in particular, as a positive activity for seniors with dementia. The Alzheimer's Foundation of America has a page discussing music therapy.
3. "You didn't Know What You Don't Know About Dementia." Lanny Butler has proven methods and unique insights into treating, managing, and coping with dementia.
4. Exercise and dance help people with dementia physically and cognitively.
5. Hearing stories of other people with dementia, such as Tennessee Volunteers Coach Pat Summitt, may motivate and reassure patients and families.
6. The Alzheimer's Association website is a great place for families and caregiver to start looking for information.
7. This YouTube video demonstrates the use of Montessori-based principles in interactions with people with dementia.
Of course, just visiting these websites will open the door for clinicians, families and caregivers to find a wealth of knowledge and ideas online concerning dementia care, therapy, and family/ caregiver support We have come a long way from the days of thinking that little or nothing could be done for people with dementia, and it is our duty as professionals to educate others.
Clinicians who are new to field or are just new to geriatric speech pathology are often unprepared or nervous about working with clients with dementia. This is completely understandable, as university speech therapy clinics typically have few, if any patients with dementia, and graduate clinical placements may or may not include long-term care facilities. Often, students learn about the causes and symptoms of dementia, and theories behind treatment, without ever meeting a patient with dementia before beginning their CFY (Clinical Foundation Year). Clinicians who have changed work settings might have been in employed in the field for years without working with a person with dementia.
Dementia can be a daunting and intimidating diagnosis to approach. The person may or may not exhibit behavioral disturbances. The person could be aware of their own communication and cognitive deficits, or might not have a clue about their change in cognitive-linguistic skills. Depression, anger and anxiety often accompany dementia. Family, caregivers, and staff will demonstrate various degrees of knowledge, understanding and support. Even fellow therapists might argue as to whether or not people with dementia can benefit from speech-language therapy.
Luckily, there are more and more resources related to dementia, and the new or less experience clinician can seek them out. I firmly believe any clinician working with adult and geriatric clients must include training in dementia and cognitive changes as part of continuing education.
Why is dementia therapy so tough sometimes?
● Staff don't always "get it." Nurses are actually sometimes trained to reorient versus validate a patient beliefs, which can increase agitation, fearfulness, and anxiety.
● Staff and caregivers may not know how to cue and support the patient, and may not carry over recommendations taught by the SLP.
● It can take weeks for a patient with dementia to catch on to new routines, activities and information.
● Staff and caregivers are often in a hurry, and do not take the time to communicate at a patient's level.
● The patient might be unpleasant, rude or inappropriate,which drives loved ones and caregivers away.
It is up to us as SLPs to set the example with patients with dementia, and to help others see the potential that all patients have. We can do this by continuing to look at treatments ideas, theories behind treatments and new research, and by presenting ourselves and the authority on cognitive-linguistic and communication deficits associated with dementia.
Next week: Web picks for dementia education and insight!
Remember those summer reading lists you got as a kid? I, for one, loved the lazy summer days when I could go to the library or bookstore and spend hours reading. Now, many libraries have summer reading lists, and even NPR has book reviews and suggested reading lists. This week, I noticed a patient reading a novel and asked her how it was progressing. This lead to some interesting conversations - recalling the plot line so far, predicting what would happen next, discussing the author's other books, and remembering our favorite and least favorite books.
Since I had not read the book, the patient offered to loan me her copy. I opted to buy it myself, and since I love to read, it was an enjoyable "homework" assignment to myself so that I could catch up with her and we could discuss the book. I also looked online for various book club discussion questions and plot synopses; yes, I was probably giving myself spoilers, but in order to use the book as therapy material I needed to catch up.
It would be difficult to read and finish every book that a patient reads, but it was fairly simple to get enough information on the book to have a discussion about it. I thought about how I could incorporate book club activities and reading into therapy, and came up with some ideas:
- Let the resident pick the author or subject.
- Plan to go slowly. Between therapy sessions with OT, PT, and speech therapy, family visits, and daily activities, it might take a while to finish a chapter. The patient might be discharged before the book is finished.
- Review information as much as needed.
- Use short stories and magazine articles instead of longer books.
- Find large print books as needed.
- Use books on tape to substitute for print as needed, or as a way to help the patient finish the book and review.
- Use audiobooks yourself if you want to catch up with your patient during your commute.
- Find articles about the author to share with your patient.
- Look in the book itself for book club questions; many books are now including discussion questions.
Using your clinical skills, book discussions can target speech, memory, word retrieval, thought organizations, pragmatics, comprehension, and more. If needed, take turns reading passages out loud with your patient.
Summer is in full swing, and while many of us are planning vacations, barbecues, and pool parties, many of our patients are unable to enjoy the summer activities that they once enjoyed. At this time time of year, patients may enjoy therapy activities that allow them to have a bit of good old summertime fun! Here are some ideas:
● Plan a mini picnic on a patio (if your facility has one) or bring a beach umbrella to set up. Serve watermelon (which the residents can help cut if they are able), sandwiches, and lemonade or iced tea. Pick a day when the temperature is not too hot, or plan for earlier in the morning or later in the evening. To make this even more fun, plan with other therapists so that they can bring a patient and treat as well. Have an indoor picnic if heat or weather is a concern.
● Collect beach sand, shells, and an ocean sounds CD, and have a beach day. Reminisce about vacations past. Build a sand castle indoors or outside with this recipe.
● Collect postcards, souvenirs and pictures of vacation spots. Ask family members to send postcards as they vacation. Use these items in comprehension, memory, and expressive language tasks.
● Find old pictures of vacation and beach wear styles throughout the years. While you use these for language tasks, try playing some beach or summertime music from the past.
● Discuss the pros and cons of different vacations spots. What was the resident's favorite vacation? Did she have any vacation disasters? How have vacations changed over the years?
● Have the patients list all the places they have visited or vacationed at, and describe what they were like.
● Bring in travel magazines.
● Discuss what residents did as children when school was out for the summer. Did they go away with relatives, work on a farm, stay near home?
● Discuss the pros and cons of travelling for vacation, and of staying home. Ask if the patients think we take enough time for vacation and relaxation, or if we take too much. Brainstorm for ideas for budget and for lavish vacations, and create packing lists and travel itineraries.
All of these activities can serve as a basis for cognitive-linguistic goals and speech-language goals. Picnic activities can include swallowing goals.
I'm always on the lookout for a new therapy activity that will be interesting and fun, and can target several goals as well as be adaptable for different ability levels. I especially like it when I find a new activity through one of the patients. Recently, a patient asked me if I wanted to play Rummikube; we played the box version, but there is an online version here. This game seems most appropriate for patients who have progressed on cognitive-linguistic therapy and have goals for sequencing, memory, problem-solving, attention, and comprehension of complex directions and information.
In my initial therapy session using the game, the patient explained the game to me, and I played by just using the information she gave me without referring to the directions. This was a great activity to target her memory, error awareness and thought organization. I made several mistakes on purpose to see if she would catch them, and I asked her many detailed questions about the game rules. Switching roles and allowing her to be the teacher also gave her a boost of confidence when she was successful at giving directions and explaining rules. We also talked during the session about how games, puzzles and other activities keep the brain stimulated and involve most of the skills we have focused on therapy.
The game was easily finished in 30 minutes that day; however, the patient was quite familiar with the game. A different patient might require more time and explanation. We played until one of us was out of tiles, but if time does not allow for that, you could always declare whomever has the lowest points total when their tiles are added up at the end of the session as the winner.
This patient is going home with family when she is discharged, and we are targeting complex cognitive tasks to promote her independence. She is aware of her deficits, and wants to be challenged. We have done cognitive tasks on paper focused on scheduling, memory, and money management, but she appreciated activities that are more social and interactive in nature as well.
Many recent graduates are starting their first jobs over the summer, or will begin their professional careers in the fall. When I see graduation announcements and hear of graduates starting new jobs, I cannot help but think of everything I wish I had known about working in the "real world" before I started. Here is my advice to new graduates:
● Be flexible and open-minded. You will have to learn to follow new routines and work under conditions that you may not have experienced up to this point. You will meet and work closely with physical therapists, occupational therapists, nurses, CNAs, dietary managers, and other professionals. Listen to and learn from them.
● Be confident. As a student clinician, your clinical supervisor most likely was seen as the person in charge. Now, you are the expert. Explain what you know, and never forget that you have years of training. Act like a professional, and expect to be treated like one.
● Expect to be overwhelmed. You will most likely have to learn a billing and documentation system, company protocols for screening, evaluating and treatment, specific building rules and regulations, and state and federal regulations. You will learn all in time. Do not hesitate to ask for help; a good employer will expect a new graduate to have questions.
● Ask a lot of questions! Do not assume or guess for fear that you are bothering someone or that co-workers will not respect you as much.
● Take your breaks and your lunch breaks. Arrive on time and leave at a reasonable time. Do not fall into the trap of overworking yourself.
● Use your CFY supervisor whenever you need help. She is there to guide you.
● Keep a change of scrubs or clothes in your car. Trust me, you will almost certainly thank me one day for this advice.
● Remain focused on the quality of care that you provide, despite pressure to be productive on the job. Yes, you can do both.
● Keep learning! Stay up to date with research and treatment options. Avoid getting into the habit of relying solely on what you learned in school. I cringe when I hear professionals say things like "That's not what we learned in school!" or "In nursing school, we were told to always reorient confused patients." And when was that? Twenty years ago? Do not become that person.
● Keep up your hobbies and interests outside of work. A happy therapist is a good therapist!
● Have a sense of humor! Humor, compassion, knowledge, and a love for your work are your greatest tools. Caffeine also helps.
Indeed, the world of speech-language pathology and healthcare has changed so much since I began that now I take so much of what I have learned for granted. All of us were new clinicians once. Good luck out there!
How many times in your professional career have you heard a statement such as, "He's a hip fracture" or "She's a stroke"? I hear it a lot, and I have to admit I cringe every time, even though I realize that the intention is to convey information about the patient as quickly and succinctly as possible. I cringe because I see patients looked at as a diagnosis, not as a person.
Our patients are not just a diagnosis, or an age, or a behavior. The simple act of saying "She was admitted for rehab due to a heart attack" takes minimal effort, and puts the person first, not the diagnosis. It may seem like a small thing, and fairly inconsequential in the grand scheme of things, but I ask you to think again: how many times have you witnessed a colleague dismiss a patient's ability to follow directions and complete therapy tasks simply stating the patient's age ("He's 96, what do you expect?") or diagnosis ("She's a level 5 on the Global Deterioration Scale; she'll never remember what we teach.").
As professionals, we owe it to our patients and ourselves to look beyond labels and medical diagnoses, and get a complete, detailed history to examine the patient as a whole. Perhaps the patient did have a fall at home and is sent to rehabilitation post-surgery, but what else is evident? Has the patient's behaviors or communication changed? Was the family starting to be concerned about the patient's memory and safety awareness prior to the fall? If we sum up a patient with a word or a number, we could very well miss an opportunity to treat the patient, particularly patients in the early stages of dementia and patients with mild communication deficits. These patients can often cover up their difficulties until they do have a fall, have surgery which involves anesthesia, or have a medical decline due to illness. Once they cannot focus on hiding the memory and cognitive deficits, the skilled clinician can often spot deficits that can be addressed through therapy and compensatory strategies.
Nursing assistants are often adept at noticing the little errors a patient makes in ADLs and social interactions. We also have to bear in mind that therapy assistants may not have the extensive training and experience to identify a communication or cognitive disorder versus what is considered normal aging. And, finally, we cannot get complacent and trust that the nurse or other therapist who has seen the patient before we evaluate has the whole story behind that patient; it is important to screen all patients carefully to determine if our services would be necessary and beneficial.
In the end, the patient with aphasia and apraxic speech and motor patterns went home to his previous setting. The patient was very anxious to go back to his former living arrangements, with familiar faces and his own belongings and schedule. He left with a walker, which had used previously, and was eating whatever he wanted and conversing with familiar people, with some episodes of word-finding difficulties and apraxic speech patterns. He was what he called "forgetful" and would rehearse new information over and over, which made some of the staff believe he was having more cognitive issues than he really was. He continued to require cues for memory and sequencing, and the team provided a great deal of education to family and caregivers so that they would would understand how we cues and assisted him and why.
One of my main concerns was that the family and other caregivers allow him to maintain his independence; it not uncommon to see family, friends, and paid helpers do even the most simple tasks for a patient out of love and concern. They often state that they want to pamper or take of a patient, because that patient has taken care of others and worked hard over the years. It is a very understandable behavior, but it can be problematic. Patients who are not allowed to try and fail, to make errors and correct them, and to get a message out or task done in their time and in their own way can begin to depend on caregivers too much. Simple tasks, like planning meals, sorting mail, folding clothes, choosing outfits, and making daily decisions are gradually taken over by caregivers who mean well, but leave the patient with reduced feelings of being a responsible adult who has some control over his or her life. Patients may become resentful, angry, sad, depressed, or begin to develop learned helplessness. The patient may begin to feel that there is nothing he or she can do independently, and so the caregivers and family will take on even more of the patient's usual tasks and activities.
Completing even the simplest of activities is important to foster feelings of self-worth and to keep the brain active. Patients must be expected to try to communicate, use memory aids, and complete simple tasks given only the minimum cues they require and with the expectation that mistakes will be made. Caregivers often get a sense of fulfillment from being a helper, but the real goals should be the patient's independence and participation and whatever level is appropriate.
Continuing on with the analysis of a complex patient with underlying dementia:
After a week or so of therapy, the therapy team began to identify dementia behaviors versus symptoms that were consistent with apraxia and aphasia. When was the patient unable to complete a task due to memory and orientation deficits versus possible sequencing and motor planning deficits? When did the patient become frustrated and give up? What part did mildly decreased speech intelligibility play in how staff and caregivers perceived this patient? What other factors came into play, including the patient's anxiety over being in a new and unfamiliar environment, and his desire to be able to walk with his walker and return to his assisted living facility, where he had friends and the staff knew him well?
As the speech-language pathologist, I took on communication, orientation, and memory skills, which the occupational therapists and physical therapists reinforced based on what I reported. The patient was actually oriented to the building within several sessions, but became anxious on his own and would let staff push him back to his room. We educated the staff about the importance of letting the patient navigate the hall to and from his room and the dining and common areas, which was important cognitively, emotionally, and physically to the patient. We realized that some of the anxiety and inability to use the wheelchair resulted from the patient's fear of having to remain in a wheelchair versus using a walker again. Consistent reassurance and education helped the patient to understand the progression of therapy and the goals. We realized that the patient took us very literally and had a poor concept of the progression of therapy; whatever we said, he expected it to happen that day or to be what would happen forever. Again, frequent review of progress and expectations helped the patient understand.
I suspected some neurogenic stuttering, and educated the staff and family on strategies to cope and support the patient. The patient became more relaxed and communicated more effectively when people learned how to listen without interrupting or speaking for him.
Next week: where was the patient at the end of therapy? Hint: It's a happy ending!
Is it dementia? Is it aphasia? Is it apraxia? Is it dysarthria? A combination of two or more?
Or is it all of the above?
I ask myself that question frequently, and it can take a careful clinical evaluation and observation during therapy to determine what is truly the most specific cause of communication problems. When patients arrive and their History and Physical (H&P) reports a diagnosis of dementia, many professional assume that communication deficits are a result of cognitive deficits, and they very well might be. Let us suppose that a patient went to the hospital with an episode of altered mental status (AMS) and a urinary tract infection (UTI). The patient also has a diagnosis of dementia and of transient ischemic attacks (TIAs). The hospital noted that the patient is a very poor historian, does not answer questions, and is oriented to person only. The patient is admitted to the SNF, and nursing staff assume that all of the communication deficits are related to cognitive deficits and that the patient simply cannot understand questions and directions.
A careful clinical exam, including components such as Brief Cognitive Rating Scale (BCRS), Global Deterioration Scale (GDS), Allen Cognitive Levels, the Ross Information Processing Assessment,- Geriatric (RIPA-G) and a speech and language sample should reveal much more about the patient's ability to communicate and that is our job: to get to the specifics of the communication disorder, treat the patient, and educate the patient and the staff so that the patient can communicate and participate in daily activities.
Patients with apraxia might be so slow to respond that the untrained person might assume that they just do not know the answer. Patients with aphasia might say it is November when it is May. Patients with dysarthria may have articulation and intelligibility deficits that result in either the patient giving up on responding, or the listener abandoning questions because they do not understand the problem. Speech and language disorders are often misinterpreted as cognitive disorders.
The patient at first did not answer any orientation questions except for questions about himself and his family. He was very slow to respond and had difficulty initiating replies to direct questions, while he often blinked his eyes rapidly and made mouth movements when asked a question. After the BCRS and GDS were completed, and the patient participated in orientation tasks during the initial therapy sessions, the patient was able to recall place, time, and situation during conversational tasks. He spontaneously announced that his birthday was in one week, and that he had been a school teacher for 40 years.
The following day, he recognized the therapist on sight, but did not recall her name. He was oriented to place, time, and situation with just a few cues, and was attempting to navigate the building in a wheelchair, which he had never used before. Each time he started to go somewhere, he required reminders of how to use the wheelchair and often stopped and looked confused. Staff assumed he was lost, and began wheeling him back to his room or to the common area whenever he stopped in the hallway. In open-ended questions, responses were inconsistent and the patient would answer several questions correctly, and then not respond to a question he had known before. The CNAs began to do almost everything for him, because they thought he is too confused to complete ADLs on his own.
What would you suspect might be happening with this patient? What would you do next?
I discovered a few weeks back that my facility's kitchen manager provides a menu of the upcoming week's meals, along with alternates, for residents who would like to plan ahead. Like all of us, residents have food likes and dislikes, and the weekly menu allows them to have some control over what they are served. At the least, it allows them to avoid liver or brussels sprouts, if those are their "thing."
I have found that getting a copy of the menu on Friday and sitting down with a patient over it is a perfect way to target many therapy goals, to learn more about the patient, and to get the patient talking about something that many people have strong opinions about. Patients have opened up over the menu, whether it's because they hate the food or think it's just fine, or whether a certain meal brings up memories of cooking for family, many people enjoy talking about food. Some patients do not have much of an appetite, and discussing the menu ahead of time may allow them to pick out which foods appeal to them more, and possibly lead to better intake and reduced reliance on snacks or supplements.
When using the menu, I often start out focused on dysphagia goals. Reading the menu might show me if the patient can identify appropriate foods and textures, or is she is aware of her dietary restrictions. I can plan ahead for upcoming treatments sessions and develop compensatory strategies based upon what the patient is stating he would like to eat. I can also involve family in the session by taking this opportunity to teach them about which foods fall naturally within a certain diet texture category and which may need to be modified, as well as by discussing compensatory strategies, safety strategies, and so on.
Discussing the menu presents me with all sorts of language and cognitive tasks, including:
- decision making, safety awareness, and problem solving (what to do if you get the wrong tray, why certain foods are restricted, etc.)
- formulating and expressing opinions
- verbal sequencing - ask patients how they make a certain dish
- word recall
- orientation (if the menu is in a calendar format)
- reading comprehension
- following directions and/attention (have the patient circle or highlight all of his likes)
I find that using the menu this way also gives the patient a sense of control and helps me to develop a rapport with him. There is nothing like bonding over food!