When and how to treat cognitive-linguistic disorders. What evidence do we have?

Starry Sky

This month’s Research Tuesday post is a guest post from the wonderful Beth Dolar. Thanks so much to Beth for sharing what she’s learned from reviewing a few articles. If you treat dementia, this is helpful information, especially when talking to people who are doubtful that SLP services will help.

Why

Research in neuroplasticity shows the brain continues to “permit flexible change” (Alves, et.al.) throughout life. What does the evidence say about treating clients with cognitive impairments? How can we support our treatments and the benefit of this population?

What

3 types of Cognitive Intervention are discussed in recent research articles:

Type What it is Examples What the research supports….
Cognitive Stimulation Cognitive social groups Newspaper review, relaxation training, apps, reality orientation These groups have demonstrated good progress, but it is unclear if the improvement is due to the social aspects or the combination.
Cognitive Training General tasks pen/paper or app based Skills training – e.g. memory, reasoning, attention, executive function, speed of processing, visualization, mind mapping, external aids Beneficial healthy aging clients. Unfortunately, carryover into functional everyday life is limited. Programs are typically structured with education of strategies, written materials and home practice.
Cognitive Rehabilitation Focused on individualized client challenges and goals External aids, organizational and attention skills, verbal categorization and elaboration, errorless learning, spaced retrieval, face-name learning, use of mnemonic strategies, mind-mapping, visual imagery Improvement in both goal performance and satisfaction. This approach has resulted in more consistent positive outcomes and client benefit – improvement in function

Who benefits

The type of dementia has a significant impact on the effectiveness of the treatment.

Evidence supports

  • Healthy adults, MCI, Alzheimer’s and Vascular Dementia types have had the most research and demonstrated the most benefit.
  • A 2012 study on Primary Progressive Aphasia from 2012 that indicated benefits in language performance and naming skills.

Limited evidence

  • Lewy Body, PD, Frontal Temporal Dementia have minimal research supporting. Secondary symptoms (e.g. behaviors, hallucinations) affect ability to participate in a cognitive rehabilitation program, which may be why there’s so little research on cognitive stimulation programs.

When

More research is needed regarding prognostic indicators for who will benefit, cost/benefit analysis, as well as the intensity, duration, frequency of the programs to maximize benefit. Most programs were 90-120 minutes a week, 1-2 times a week, for 6-10 weeks.

How

Clients tended to benefit most when trained with individualized compensatory strategies rehabilitation. The benefits were less/did not carryover to function for general stimulation. Consider the diagnosis, client insight and motivation/likelihood to implement, when determining appropriateness. If a client is motivated, likely to utilize the strategies, then research does support individualized training in strategies, use of external supports. Individualized goals, client carryover and implementation of the strategies is key.

Documenting for reimbursement

  • Prognostic indicators – document the diagnoses that has research to support use of the interventions. Document motivation, evidence of client practicing skills between sessions, carryover evidence – all these support effectiveness and potential for long-term gains. Of course, client age, time since onset, caregiver support are also important prognostic indicators to consider.
  • Skilled Interventions – What is the client learning from you that they won’t if they just do an app or crossword puzzle by themselves. What makes it “Rehabilitation” rather than just “Stimulation” or “Training”? How are you going to facilitate carryover into function? Document client responses to your education. Did the client ask questions about or restate the information? Did the client return demonstrate the technique?
  • Pre-post measurements. Objective (e.g. SLUMS, SAGE, ABCD) as well as subjective – client’s perception of their function and skills (e.g. CETI, ASHA FACS or Functional Communication Profile). Some research did not show a statistically significant improvement in test scores, but did improve client’s perception, confidence, or functional improvement. Client quotes can also demonstrate benefit / carryover.

References
Alves, J., Magalhaes, R., Machado, A., Goncalves, O., Sampaio, A., & Petrosyan, A. (2013). Non-pharmacological cognitive intervention for aging and dementia: Current perspectives. World Journal of Clinical Cases WJCC, 1(8).

Bourgeois, M. (2013). Therapy Techniques for Mild Cognitive Impairment. Perspect Neurophysiol Neurogenic Speech Lang Disord Perspectives on Neurophysiology and Neurogenic Speech and Language Disorders.

Fleck, C., & Corwin, M. (2013). Evidence-based decisions: Memory intervention for individuals with mild cognitive impairment. EBP Briefs, vol. 8, 1–14.

Guest Blogger Bio

Beth Dolar, M.S. CCC-SLP enjoys collaboration with other disciplines in a variety of settings with all ages of clients, including skilled nursing/long term-care facilities, outpatient, home health, and telepractice. She is currently expanding her private practice with focus on aphasia recovery and communication for dementia. She graduated from University of Wisconsin – Stevens Point. A mother of two, she enjoys exploring creativity, the outdoors, and travel. You can find Beth online at Speech Spark.

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Rachel Wynn

Speech-Language Pathologist at Gray Matter Therapy
Rachel is a speech-language pathologist and creator of Gray Matter Therapy. She started making noise as a patient-centered care advocate in 2013. She believes great care happens when patients are informed and engaged.
Rachel Wynn
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  • Beth Dolar

    Thank you for the opportunity to guest blog for you!

    • http://graymattertherapy.com/ Rachel Wynn

      Thank you for writing a great post!

  • Elana Shinkle

    Although treatments overlap, I believe the individualized approach is key. I will keep these data in mind for the next time I serve the SNF population! Thank you for taking the time to review the studies.

  • http://www.therapistsunlimited.com/ Symen James

    As an aspiring SLP myself, I’ve learnt the important role that we have in helping people out with their communication ability. I just can’t wait to get my first speech language job and get started with my career.