Alzheimer’s Disease – Communication Challenges And Strategies For Speech-language Pathologists

By Jessica Bull, MS, CCC-SLP

Speech-language pathologist

The incidence of Alzheimer’s disease around the world is on the rise. According to the Alzheimer’s Disease Facts and Figures Report, 5.8 million people in America live with the disease. This number is projected to rise to 14 million people by the year 2050. In all, one in three older adults die with Alzheimer’s or some other form of dementia!

Many people associate Alzheimer’s with memory loss, but the destructive nature of the disease includes so much more. From loss of memory starting with the newest and most recent memories to loss of the ability to feed and clothe oneself, the realities of this disease make it absolutely understandable that receiving a diagnosis of Alzheimer’s can be overwhelming and emotionally devastating

At this time, scientists are working hard to find a cause and a cure for Alzheimer’s disease, but we’re not there yet. In the meantime, much can be done to alleviate the impact of symptoms with the help of a speech-language pathologist. As SLPs, we can have an impact in helping people with dementia, and everyone surrounding them, understand the changes in communication, memory, attention, and strategies to compensate for loss of skills. Referrals from a physician for SLP following functional decline can assist with the implementation of techniques that match the individuals’ current skill set.

TOOLS SLPs CAN USE TO ASSESS DEMENTIA

Evaluation of cognitive deficits using screening tools can be completed by any medical professional. By using the Global Deterioration Scale, the slow decline and losses caused by Alzheimer’s can be measured in stages thus giving people a clear understanding of where an individual is functioning. The GEMS scale is another dementia classification tool designed by Teepa Snow, is useful in looking at both decline of skills and retention.

Family and caregiver interview checklists can be beneficial to understand how the loss of skills is affecting functional task completion and independence levels. These lists can also tell us how everyone is already compensating for cognitive changes.

Once the stage has been determined and specific skill loss can be described, speech-language pathologists can begin to determine how best to set up the environment with visual cues; reduce distractions; train caregivers, family, and other medical professionals on how to modify their communication. During earlier stages, SLPs can teach the person with dementia how to continue to communicate effectively and participate in cognitively challenging tasks to maintain their skills as long as possible.

From the beginning stages of decline in dementia, communication can become a challenge. In very mild cognitive decline, symptoms can be subtle, like the loss of memory for where an object was put down or familiar names.

During these early stages, we can focus on training the patient to compensate using total communication strategies (gestures, circumlocution or descriptions, and use of synonyms). The patient will benefit from setup of cognitively challenging tasks and exercises. Dr. Rob Winningham’s trainings and website are great resources for learning how to design a program beneficial for attention and working memory, and retention of short-term memory as long as possible.

Family and caregivers will benefit from education to prepare for changes to monitor. We can also provide them with instruction on compensatory strategies to assist the patient in maintaining written documents.

A memory book can be created that includes important personal and medical information. With this, the patient can continue to reference as the disease progresses and retain the ability to access previously learned information and important facts about themselves.

Implementing a clear and simple calendar setup with a dementia clock for an older adult that clearly shows the day and date nearby can be impactful. Medication schedules can be used where an alarm is set (even Alexa can remind!) and medications are clearly marked to ensure that the correct amount is taken at the right time.

In the early stages, memory strategies can be very helpful to retain new information, including writing things down (daily journal, phone notebook, etc.), spaced retrieval training, visualizing, chunking, and a memory booking.

The person will then progress to the more easily recognizable stage of mild cognitive decline.  The person may get lost going to a familiar place, forget words and names, forget what they read, and lose items frequently. Trouble concentrating, remembering the date and time, or recalling some information about themselves may also start to develop as decline becomes more moderate.

They will likely have difficulty recalling main details of personal history, like an address, or telephone number. Though people with Alzheimer’s can continue to do things like toileting and eating, making a meal or choosing weather-appropriate clothing can become difficult. During this stage, independence is often lost thanks to inability to manage finances, navigate routes, or track appointments. It is beneficial for the rehabilitation team to work to work together to modify the environment, simplifying visual cues, and reduce distractions.

AN SLP’S INTERVENTIONS FOR ALZHEIMER’S

We work to help family and caregivers learn to adapt to lost communication skills or word retrieval deficits by beginning to use supported conversation strategies, including slowed rate of speech, simplified sentence structure, gestures and facial expressions, frequent pausing, 90-second wait time, providing context and pictures whenever possible, and using simple yes/no questions or questions with limited answers.

As the disease progresses and it becomes harder for the person to understand reason and complex ideas. Validation can help to calm agitation and regain control of a situation by recognizing emotions, giving them a name, and acknowledging how the person feels is completely justified.

The most significant changes are seen in the later stages of dementia. We see severe cognitive deficits. A person can no longer consistently recall or retell familiar information about themselves, retain any recent information, or recall family names and relationships (though they are usually still able to recognize that someone is familiar to them). In these later stages, communication is generally lost. Because of the severity of changes to brain matter, people become unable to feed or clothe themselves in the late stages of the disease and rely completely on family and caregivers for even the simplest of tasks.

It is very important for clinicians to focus on family and caregiver training in later stages. Patients are more likely to follow hand-under-hand cues. The GEMS scale provides ideas like this for how best to deal with the changes. For example, in one of the later stages named “Ruby,” the model describes some of the losses but focuses on how music is a powerful tool and how people in the latest stages of the disease often still attend and even participate in singing activities. Patients may also be able to follow nonverbal cues (facial expression, tone of voice, touch). The patient may not understand any word meanings, but will likely still have a positive response to preferred music.

As communication skills are lost, it becomes very important to pay attention to nonverbal signals and what they may indicate. For example, the Abbey pain scale is useful for determining location, severity, and appropriate treatments during sessions for when pain levels can no longer be communicated.

Loss of communication and life skills can be devastating and isolating, and families go through grieving periods as their loved one with Alzheimer’s declines. It is important to keep in mind that the person with Alzheimer’s would never choose the disease.

It is vital to have a variety of resources in place for people with dementia along with their family and caregivers. Appropriate supports include appointments with knowledgeable geriatric medical professionals, referrals for speech and occupational and physical therapy as physical and mental declines are noted, online or in-person support groups, educational information and websites like the Alzheimer’s Association.

All of these supports can help patients and their families adapt to cognitive changes and maintain quality of life and dignity through the end stages of the disease.