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.)