Case Study: Dementia – communication

Introduction

I have started to receive more and more stroke referrals for patients who have vascular dementia. I have liaised with a dementia specialist for some advise on the following patient.

Referral

For SLT to improve the patient’s intelligibility.

History

• Stoke
• Reported diagnosis of dementia.
• Recent chest infections and decline in function (falls + infections).
• Previously SLT focused on using a life review book during conversations with friends at a day centre.
• Bilingual - English and Italian.
• The patient's wife reported that his language skills are at baseline.
• She reported that the patient does not consistently recognise family members (herself/ daughter) and forgets information very quickly. The patient's wife reported that the patient is not intelligible on the phone and that they often talk to family on the phone.
• The patient reported that he has speech difficulties.

Assessment

The patient was asked questions about pictures of family members (a familiar topic). The patient’s wife was asked about her husbands change in function.

Speech characteristics

Non-fluent, stuttering speech. Difficulties with word initial phoneme's - phoneme repetitions. Quiet speech, unclear articulation and reduced breath support.

 Intervention

  

Carer focused intervention - patient cannot remember strategies.

Strategies were handed over because the client was able to use them when prompted repeatedly.

Recommended  skype instead of phone use with distant family.

Normal dysfluency advice - decrease anxiety, not interrupting the patient when speaking, prompting him to pause between words, slow down his speech and prolong sounds which he has difficulties with.

Modify environment decrease background noise + distractions.

Advice from dementia specialist SLT

Progressive - therefore maximise present skills e.g. non-verbal comm.

Book ' care to communicate - Jenny Powel' - aimed at carers with dementia

-

Questions to ask/ key things to consider with a dementia client:

• Full diagnosis of dementia ? memory clinic report?
• Can the patient use communication strategies when prompted?
• Insight? E.g. this patient demonstrated some insight into speech intelligibility/difficulties
• Carer education
• Communication of basic needs
• Maximise the patient’s communication strengths e.g. non verbal communication.

MDT community informal assessment questions

OT

• Are you less able to participate in any activities of daily living than before your stroke?
• Have you had any falls/ near falls? Do you have a plan if you do have a fall e.g. a pendant alarm?
• Cognition – planning/ sequencing/ memory: what would you do if your toaster caught fire?  how do you make a cup of tea? What month/day/year is it?
• Do you have a care package?

PT

• Has your ability to move (walk/transfer) changed?
• How is your balance/ leg strength?
• Had your ability to change position changed since your stroke?

SLT

• Is your speech slurred/ different from normal?
• Can the client follow one/two/three stage instructions?
• Do you have difficulties thinking of the right words/ is the patient’s speech non fluent?
• Eating/drinking – Any new difficulties with eating/ drinking e.g. Coughing/choking/ fluid coming out of nose/ mouth when drinking, chest infections/ weight loss.

Stroke

• Are you aware of any stroke services/ charities e.g. disability benefits, the stroke association, befriending…..
• Have you booked an appointment for a review with your GP now that you are back from hospital?

Community SLT referrals

Adapting from working in an inpatient setting to working in the community has given me some insight into what makes a good community SLT referral. If i could go back in time......


Ingredients for a good community referral

1. Formal Assessments - e.g. the CAT/ Frenchay or outcome measures such as the DOS. 
2. Baseline - clear information on the client's baseline of function.
3. Goals - goals achieved in hospital, goals which are open and potential community goals.
4. Background information - regular visitors? living with family? 
5. Send the referral (nhs.net email or fax + check if received) the day before or two days before discharge and call to handover any complications.

Dysfluency - reflection

Think of a recent therapy session.

First two appointments with an 80 year old actress who's stutter had recently deteriorated.

Describe the experience

I had never worked on dysfluency with a patient. I asked the patient for a history of her dysfluency and a medical hstory. She had a diagnosis of Parkinson's but had had a stutter as a child and her dysfluency appeared to be due to a stutter rather than a dysarthria. I used the 'Overall assessment of the speaker's experience of stuttering' (OASES) to get a baseline for therapy. This assessment involved getting information on the patient's reactions to their stuttering, communication in daily situations and quality of life. I haden't quite been prepared enough for the way the questionnaire elicited personnal/ emotional reflections/ information.

How did this make you feel?

I felt empathetic torwards the patient and felt that it was the first time i had truely considered the emotional impact of having a stutter. I made a conscious effort to listen to the patient's experiences.

What would you change and why?

I would revise my counselling training materials and really consider how i could incorporate these skills into a therapy assessment session.

Montreal Cognitive Assessment

I often get handovers from different therapists with MOCA scores. I thought i would further research what the MOCA assesses and what the diifferent scores mean.

Z.S. Nasreddine et al (2005) The Montreal cognitive assessment, MOCA: A brief screening tool for mild cognitive impairment, Journal of american geriatrics society, 53(4), p605-699

Introduction

• 1 page, 30 point test taking 10 minutes.
• 26 or above is considered normal.
• Apraxia of speech - reduced score due to repetition difficulties/ naming difficulties.
• Receptive aphasia - reduced score due to reduced ability to understand instructions.
• Expressive aphasia - reduced score due to naming impairments/ word generation difficulties

Why was the MOCA created?

• Very sensitive to mild Alzheimers disease (100% predictor in one study), and mild cognitive impairment (89%).
• Usefull for assessing mild stages of the cognitive impairment spectrum.

Assessment	Task
Visuospatial abilities Short term memory recall Attention Working memory Language Orientation to time/ place	- Clock drawing/ cube copying - reading ‘face, velvet, church, daisy, red’ – recall after 5 minutes. Tapping task – tap when say ‘A’ Serial subtraction task (taking 7 away from 100) Confrontation naming task (camel, lion, Rhinoceros). Repetition of 2 syntactically complex sentences. Word fluency task (words beginning with F in one minute, norm = 11 words). Date, month, year, day, place, city

Dysphagia Outcome Scales

In this current healthcare climate i've started to realise that i need to use more recognised/stardardised empirical measures and standardised outcome measures to proove the worth of my interventions. One area i feel i've neglected is dysphagia. I write detailed observations and goals but need a static scale or measure to clearly demonstrate change after intervention. I've chosen one impairment based scale and one functional scale. I've decided to try and incorporate the following scales into my practice:


The Dysphagia Outcome and Severity Scale , (DOSS) - a 7-point scale developed to systematically rate the functional severity of dysphagia based on objective assessment and make recommendations for diet level, independence level, and type of nutrition. (O'Neil, Purdy,Falk,Gallo,1999).

Level 7: Normal in all situations

Level 6: Within functional limits/ Modified idependance

Level 5: Mild Dysphagia:Distant supervision. May need one diet consistency restricted

Level 4: Mild Moderate Dysphagia .Intermittent supervision /cueing; One to two diet consistecies restricted

Level 3: Moderate Dysphagia. Total assisstence , supervision or strategies;2 or more diet cosistencies restricted

Level 2: Moderate Severe Dysphagia: Maximum assisstance or maximum use of strategies with partial PO only

Level 1:Severe Dysphagia: NPO: Unable to tolerate any PO safely (National Dysphagia Diet Task force,American Dietetic Association,2002)

The Functional Oral Intake Scale (FOIS)

Crary MA, Carnaby GD, Groger ME. (2005) Initial psychometric assessment of a functional oral intake scale for dysphagia in stroke patients. Archive of physical medicine and rehabilitation. 86, 1516-20.

TUBE DEPENDENT (levels 1-3) 

1 No oral intake  

2 Tube dependent with minimal/inconsistent oral intake 

3 Tube supplements with consistent oral intake 

TOTAL ORAL INTAKE (levels 4-7) 

4 Total oral intake of a single consistency 

5 Total oral intake of multiple consistencies requiring special 

preparation 

6 Total oral intake with no special preparation, but must avoid 

specific foods or liquid items 

7 Total oral intake with no restrictions 

Community SLT

Think of a recent therapy session or event.

I’ve just completed my first month working in a community SLT service.

Describe the experience

I work between 3 teams (neuro, stroke and community) managing my own caseload and screening referrals for the stroke team. I average around three home visits a day, less sometimes on days with meetings and more on other days. At times I have found it hard to keep track of all of the admin I need to complete and sometimes forget to record all correspondence/ time spent doing admin. Gathering client history information and contacting GP's/ hospital therapists for information has been surprisingly difficult.

How did this make you feel?

I have enjoyed being out of my comfort zone. I feel that I am learning to become better at communicating with other teams e.g. charities, GP consortiums, Hospital therapists etc and with managing a complex caseload.

What has this taught you?

• To keep a weekly to do list with all of my patient’s on it.
• To upload any letters I send to GP’s/ write down on RIO when I try to contact other services e.g. by phone but do not get through.
• To make a careplan for new complex patients in which I record assessment results, goals and therapy activities/ desired outcomes.
• To timetable in time for admin (discharge reports etc.)

Progressive Supranuclear Palsy

I've just started a community job and am having to learn more about progressive conditions. Here's some info on PSP.

PSP

• Neurodegenerative parkinsonian disorder.
• Typically presents in middle/late age with progressive unexplained postural instability, falls, supranuclear gaze palsy, pseudobular palsy and mild cognitive disturbances.
• Cause: progressive damage to the basal ganglia and brainstem.
• Begins slowly and leads to continuous decline.

Observations

• Personality changes (apathy/forgetfulness/irritability/lability)
• Blurring of vision, problems controlling eye movement e.g. problems looking down/ with eye contact.
• Slurred speech and dysphagia (often more severe than in Parkinsons).

Dysphagia

• Pneumonia = the most common cause of death
• People may live up to 10 years with proper interventions.

Leopold et al (1997) Dysphagia in progressive supranuclear palsy: radiologic features, dysphagia, 12(3), 140-3.

Key features

• Uncoordinated lingual movements
• Absent velar elevation/retraction
• Impaired lingual displacement
• copious pharyngeal secretions
• non cohesive lingual transfer
• oral bolus leakage into the pharynx
• significant vallecular residue
• reduced oral sensation

Key observations

• Difficulties chewing/ with the oral stage of swallowing mean that softer foods may be easier. 85% of the patients with PSP had oral stage difficulties. 
• Most of the patients had pharyngeal stage problems which may have been caused by the oral stage impairments e.g. pharyngeal overspill.

Example Recommendations

• Avoid mixed textures/ hard chewy foods.
• Decrease distractions
• Put the plate high up if the person cannot look down.
• Encourage a clearing cough post swallow
• Make the patient more aware of the oral stage e.g. write Step 1, 2, 3, 4.

Observations from a videofluoroscopy of a patient with PSP

• decreased coordination of lingual movements, especially the base of tongue. Pre-swallow loss of bolus'.
• +++ vallecular residue on soft food (banana + yogurt) but no aspiration.
• Small amount of aspiration on thin fluids when taken after eating.
• No aspiration on syrup thickened fluids taken after eating - this helped clear the vallecular residue.

Recommendations from the VF

1. Syrup thick fluids at mealtimes.
2. Sips of thin fluids throughout the day (for QOL)
3. SOft mashed diet.

Case Study: Apraxia

Here is one of the most successful therapy interventions i have planned. Initially i tried to set goals around gesture use, picture symbol use and comprehension. As i observed the client in OT and PT sessions it became clear that their apraxia of gestures and of speech made their comprehension appear more severely impaired on impairment based assessment than in reality. Once I set goals around speech, which was motivating for the client he progressed very quickly.

History

·       60, left MCA infarct, LPCA infarct affecting the left frontal lobe and left parietal lobe, history of alcohol excess and cannabis abuse. The patient was very musical, played 3 instruments and enjoyed singing. One nephew visited the patient. Previous SLT report – Comprehension- unable to consistently select the correct pic from verbal stimuli. Diff following simple instructions. Expression – ‘yes’ to all Q’s, no other verbal output, inaccurate pointing.

Assessment

·       Object to pic matching – able to do with everyday objects. Yes/ No response to orientation questions/ simple questions in context – patient was inconsistent due to ideational apraxia and apraxia of speech. Best Yes/no interpretation = from body language and tone of voice.

·       OT/ PT joint sessions – patient was able to follow simple instructions in context. Difficulties copying actions.

·       Word repetition/ apraxia assessment – patient presented with severe apraxia of speech.

·       Language screen – groping for words expressively, unable to follow complex directions e.g. 3-stage (thought to be due to apraxia of gestures). Pre-morbid literacy impairments.

Goals

Long term (0ver 2.5 months)

I will be able to consistently communicate my basic needs by using total communication strategies (pictures, gestures, drawing).

I will be able to spontaneously use 5 functional words in context.

Short term

I will be able to communicate a consistent Yes/No response when prompted to use a communication aid.

I will be able to use pictures to communicate functionally during a kitchen/ wash and dress task.

I will be able to consistently understand picture symbols relating to my everyday needs.

Smart goals

I will be able to imitate the following sounds consistently when given visual prompts: ‘mm’ ‘me’ ‘yo’ ‘yes’ ‘no’.

I will be able to spontaneously say ‘yes’ or ‘no’ appropriately when asked an appropriate question.

I will be able to consistently use 5 topic cards (Body, family, therapy, food, activities) with trained members of staff to communicate a piece of information.

I will be able to use ten functional words (tea, coffee, Bob Marley, physio, pain, medication, Thomas, toilet, shower) consistently and spontaneously in context.

I will be able to say 10 functional phrases within specific contexts (e.g. breakfast group, physiotherapy, with the doctors…).

My nephew will be able to identify strategies (using topic cards, yes/no questions, pauses…) to support me to communicate, during a short conversation.

Therapy Activities

1.     Joint sessions with the OT/ PT around comprehending instructions and responding consistently to yes/ No questions.

2.     Apraxia Exercises – starting with vegetal sounds/ sounds that were easy for the patient to make and using topping to facilitate speech. Phonemic prompts and finally modelling of the word were used as a step down.

Yawn (open mouth wide)	‘ah’
Hum (keep mouth closed and vibrate)	‘m’
La la (singing) (curl tongue up and down)	‘l’
Bite lower lip	‘f’
Damming the lips	‘p’
Tut tut	‘t’

Yeah	·       Tap (extended) ·       ‘y’ ‘air’
Oh Gosh	·       tap,  tap (extended) ·       O  gosh
Hello	·       tap tap ·       cough (humpf), laugh ·       he  lo
Yes	·       tap (extended) ·       yeah ·       yeah sss
No	·       tap ·       ‘nnn’ ‘ooo’
Good	·       Tap ·        ‘g’ ‘ood’
Got	·       Tap ·        ‘g’ ‘ot’
Gone	·       Tap (extended) ·        ‘g’ ‘one’
Bye	·       Tap ·        ‘b’ ‘I’
Down	·       Tap ·        ‘d’ ‘own’

3.     Apraxia exercises – semantic clues e.g. you might drink it, pictures and carrier phrases were used to elicit chosen functional words/ phrases. The patients accent was considered e.g. ‘th’ was difficult so ‘d’ was used instead, as with the Caribbean accent.

4.     Topic card use in supported conversations.

5.     Joint sessions with the psychotherapist  - talking about motivating topics e.g. family, coming to the U.K., spiritual beliefs, dealing with a stroke.

Outcomes

-        Consistent yes/ no responses for simple questions.

-        Some functional word/ phrase use in context.

-        Some spontaneous sentences/ and carry over to words not practised in therapy.

Referrals

·       Referral made to community services with potential goals around facilitated conversation with the patient’s nephew and functional communication goals around shopping etc.

Gesture and apraxia

Mengotti, P et al (2003) Selective imitation impairments differentially interact with language processing, Brain, 136, 2602-2618.

Introduction

• Ideational apraxia - patient struggles to come up with a plan/ idea for how to use objects (sequencing may be incorrect..)
• Ideational apraxia - difficulties translating an idea into movement e.g. with imitation.

Methods

• 57 patients with damage to their dominant left-hemisphere were tested on: 1) ability to process language, 2) Use objects functionally, 3) imitate meaningful gestures, and 4) imitate meaningless gestures.

Results

• The patients' ability to imitate meaningful gestures and their performance on naming/ repetition tasks appeared to be related. Whereas their imitation of meaningless gestures was correlated to the patients' comprehension.

Conclusion

• Imitation of familiar gestures relies on the language system because these gestures are linked to the corresponding lexical semantic representations.
• The angular gyrus is important for gesturing.

How does this relate to practice?

• Meaningless gestures - if a patient is unable to imitate meaningful gestures perhaps you could try new gestures which you then develop new representations for e.g. fidt/palm for yes/no.
• Increase in the use of meaningful gestures may be a positive diagnostic sign for naming/ language.
• There are two separate pathways for gesture imitation (one via semantics and one not).
• Working on gesture/ total communication may positively impact language/ naming.

Tongue/ oral control ex's

TONGUE

1.     Open your mouth and poke out your tongue.  Be sure your tongue is straight out, not resting on your lips or pointing to either side.  Hold this position for 2 seconds.  Practise slowly 10 times.

2.     Open your mouth and this time pull your tongue right to the back of your mouth.  Practise this slowly 10 times.

3.     Poke out your tongue and move it slowly from corner to corner of your lips.  Practise this slowly 10 times.

4.     Poke out your tongue and move it from corner to corner as quickly as you can be sure to check that it is moving right into each corner.  Try this 5 times.

5.     Poke out your tongue and point it down towards your chin.  Hold it there for 2 seconds.  Practise this slowly and carefully 10 times.

6.     Poke out your tongue and try to point it up towards your nose.  Hold it there for 2 seconds.  Practise this slowly 10 times.

7.     Lick your lips slowly and carefully.  Practise this 10 times.

8.     Put your hand on your cheek (your stronger side).  Now put your tongue in your cheek and push against your hand.  Practise this 5 times. Now try exactly the same thing but on your weaker side.

9.     Practise clicking your tongue off the roof of your mouth. 

Do this 10 times.

Tongue/ oral control exercises

-       Chewing ice/ moving around in mouth.

-       Moving a polo on a string in the mouth

-       Use a spoon as a reference point – touch the spoon with your tongue.