Speech-Language Pathology: Cognitive Therapy For Dementia And Beyond

By Gail Kemeny, MS, CCC-SLP

Speech-Language Pathologist

In working with older adults, we recognize that some changes in cognitive function such as processing speed, forgetfulness, and decreased attention happen, and are a normal part of aging. However, when we consider that one in 10 adults over the age of 65 has Alzheimer’s disease, as stated by the Alzheimer’s Association, it is not surprising that an overgeneralized belief that the development of cognitive deficits which impact an individual’s daily functioning, safety, independence, and general quality of life is a “normal” and untreatable process of aging.

In fact, I once encountered a medical professional who proclaimed, “If we live long enough, we will all get dementia.” The problem with this belief is that the over-acceptance of cognitive changes in older adults may lead to many individuals with cognitive impairments not receiving the care they need and deserve.

Some individuals with cognitive impairments do not seek medical intervention due to the fear of receiving an Alzheimer’s diagnosis, limited awareness of their deficits, a belief that the deficits are “normal,” or the perception is that nothing can be done. Unfortunately, this misconception can be perpetuated by other members of the individual’s social group and even occasionally the individual’s healthcare providers.

Many healthcare providers are aware that although we are not currently able to reverse or stop the progression of Alzheimer’s and dementia, there are a variety of interventions that can assist with slowing the progression of cognitive decline and promote increased ability to cope with the illness. According to research by the National Center for Biotechnology Information as well as the Department of Speech and Hearing Sciences at Indiana University, there is evidence to support the benefits of medication use, participation in physical activity, behavioral and environmental modifications, and participation in speech-language pathology in the treatment of Alzheimer’s and dementia.

HOW SPEECH-LANGUAGE PATHOLOGY CAN ASSIST WITH COGNITIVE DECLINE

The awareness of speech-language pathology’s benefits for individuals with Alzheimer’s is slowly growing throughout the healthcare community. Individuals at every stage of the disease can benefit from intervention.

A speech-language pathologist can assist with dementia staging through education on current and potential future functioning. This is done via support with nonverbal communication strategies. Additionally, speech-language pathologists can help these older adults with the development and implementation of compensatory strategies to assist them and their caregivers with maximizing independence and quality of life within the constraints of the individual’s current abilities.

However, Alzheimer’s, while prevalent among older adults, is not the only cause of cognitive deficits. What about those individuals who are struggling with cognitive impairments from an illness or disease other than Alzheimer’s? Can speech-language pathology also benefit those individuals? More often than not, the answer to this question is a resounding yes. Let’s consider a few of these diagnoses.

CEREBRAL VASCULAR ACCIDENT

On average, 75 percent of strokes occur in people 65 or older. Obviously, speech-language pathology is beneficial for individuals suffering from verbal expression and receptive communication deficits status post-stroke. However, when we consider that anywhere from 20 to 80 percent of individuals who suffer strokes have a post-stroke cognitive impairment, per the Annals of Translational Medicine, we must consider the importance of therapeutic intervention for cognitive abilities as well the linguistic aspects.

One of the key questions that a speech-language pathologist will seek to answer when assessing a person following a stroke is, “What is causing the communication breakdown: verbal expression deficits, receptive communication deficits, or cognitive deficits?” It is important for pathologists to differentiate the root of the communication breakdown in order to effectively assist the patient with restoring or compensating for their communication deficits.

Expressive communication deficits are often addressed with linguistic exposure and repetitive tasks for naming and verbalization. Multimodality input and increased processing time help with receptive communication deficits. Memory deficits are often dealt with by training the patient on the use of compensatory strategies or practice with recall.

Consequently, due to the varying methods for intervention with each root cause of communication breakdown and the frequency of cognitive impairment in individuals who have suffered a stroke, speech-language pathologists are compelled to consider cognitive function in their CVA assessments.

TRAUMATIC BRAIN INJURY

An individual who suffers from a traumatic brain injury can present with deficits in attention, executive function, information processing (receptive communication), memory, metacognition, orientation, and spatial cognition. A basic speech-language pathology assessment will examine each of these areas of cognition to determine which components are affected, and the severity of the impairment. Interventions are developed based on each individual’s type and severity of impairment.

While TBI is not the first diagnosis one thinks of in reference to older individuals, their increased risk of falls, miscellaneous injuries, and car accidents place them at risk for sustaining a traumatic brain injury. A speech-language pathologist can help across the spectrum of severity. In individuals with severe deficits, the speech-language pathologist will help to establish meaningful interactions. In individuals with minor deficits who have already established compensatory strategies for dealing with their cognitive deficits, a speech-language pathologist may be needed to develop new compensatory strategies when the individual has to transition to a new level of living.

OTHER FORMS OF DEMENTIA AND NEUROLOGICAL DISEASES

Although the benefit of speech-language pathology with Alzheimer’s dementia was previously established, it is important to note that not all individuals with dementia are struggling with Alzheimer’s disease and each form of dementia progresses differently. For instance, frontotemporal dementia will have an early onset, fast progression, and will likely result in behavioral deficits. On the other hand, Parkinson’s dementia will have a late-onset, a slower rate of progression, and fewer behavioral considerations. Although an individual’s primary care provider and his or her neurologist can explain the variations in disease processes, the speech-language pathologist, in working to support recall, can provide additional educational support.

Additionally, the SLP can develop an individualized plan of care just as they would for patients with Alzheimer’s. Behavioral assessment and planning for future care needs may be the primary focus of individuals with frontotemporal dementia. Consideration for engaging individuals in cognitively stimulating activities in the presence of movement deficits may dominate therapeutic intervention with Parkinson’s disease, multiple sclerosis, and other neurological illnesses.

Speech-language pathologists work closely with the individual, their family, their caregivers, as well as their physical and occupational therapists to provide a holistic approach to cognitive intervention to maximize an individual’s function.

MILD COGNITIVE IMPAIRMENT

It is well known that individuals who struggle with mild cognitive impairment are at greater risk of developing Alzheimer’s disease. Consequently, the line between mild cognitive impairment and the early stages of dementia can become blurred. However, it is important to be aware of the differences in the two types of impairments from an intervention standpoint.

For instance, mild cognitive impairment has a myriad of disorders associated with the root cause, including diabetes, hypertension, hypercholesterolemia, obesity, and depression to name a few. It is imperative to treat the associated disorder to promote the resolution of the cognitive impairments.

However, even with appropriate medical treatment, impairments do not always resolve as quickly or completely as one would hope. At this point, speech-language pathology intervention can become crucial to individuals’ safety and recovery. Among other things, those who struggle with mild cognitive impairment may present with difficulty recalling when to take their medications. They may struggle with solving problems related to their medical needs or activities of daily living. They may struggle with temporal orientation and schedule management which, in turn, impairs their participation in both social and medical appointments.

A speech-language pathologist can help develop routines and reminders for medication management, enhance problem-solving skills or simplify complex tasks to support safety, and develop compensatory calendars and schedules to assist the patient with activity participation. Unlike individuals struggling with progressive disorders, an individual with mild cognitive impairment has the potential to restore their cognitive function rather than simply compensate for the deficit. Speech-language pathology can help guide and direct this restoration of function.

Overall, as professionals who work with older individuals, it is important for all of us to be alert for changes in cognitive function. We should strive to encourage individuals to seek answers for the cause of their cognitive deficits and reassure these individuals that there is help. Speech-language pathology is a powerful tool to help a variety of individuals navigate the frightening process of cognitive function changes.