Dementia & the Capacity for Learning: a Speech-Language Pathology Perspective

By Shannon Stocks MS, CCC-SLP

Speech-Language Pathologist

A man sits alone in his worn leather recliner, one leg propped up on the coffee table in front of him, another tapping to the beat of an indistinguishable Bobby Day song. He leans back, his nostrils catching a whiff of buttered toast. An unfamiliar woman enters the room, her lean arms bearing a plate of steaming scrambled eggs and a sloshing cup of coffee.

“Don, time for breakfast. Come get up and wash your hands. Why don’t you sit down over here by me at the dining room table? I made you some decaf coffee this morning–I don’t want you up quite as late as you were last night.”

Her words appear thoughtful, yet for Don, they blend together. He only catches a couple of phrases: eggs, wash, sit. Did she want eggs washed? Don can tell by her eyes that she is kind, and she certainly knows his name, but he cannot place her voice. Come to think of it, he cannot place where he is at all.

“Is this … your apartment?” he asks hesitantly.

“Don,” she starts. Her cheeks are becoming hot and she can feel her voice growing in frustration. She pauses and takes a breath. “Just, come and wash your hands.”

~~~

What is Dementia?

Chronic and distressingly common, dementia is a three-syllable word with a multitude of connotations. Certainly, dementia is defined by a progressive loss of memory, lack of awareness of memory impairments, and personality changes; yet each individual exhibits a wide variety of characteristics. Each respective clinical presentation depends on the current stage and type of dementia. Alzheimer’s Disease (AD) is the most prevalent variety of dementia and the stone most commonly unturned.

What is Dementia’s Impact on Memory?

There are two distinct types of memory affected by Alzheimer’s disease. Declarative memory is the recall of recent details, such as the contents of a kitchen calendar or Sunday paper. Procedural memory refers to the sequencing of familiar activities, such as getting in and out of bed or showering. Learning a new skill requires building upon declarative memory while retaining activities of daily living (ADLs) calls upon procedural memory.

Currently, a diagnosis of AD based on behavioral presentations alone is considered to be a probable one until confirmed by an autopsy or MRI changes that indicate brain atrophy, amyloid plaque deposits, twisted tau protein tangles, or nerve cell death (Villemagne et al., 2013). AD primarily affects particular sections of the brain, including the supplementary motor cortex, basal ganglia, and cerebellum (Reiman, et al., 2012). Autopsies reveal that extensive nerve atrophy and death occur in advanced stages of this disease, which explains deficits in orientation and short-term memory.

The question remains why individuals diagnosed with AD demonstrate difficulty with day-to-day tasks if the areas of the brain for these tasks remain intact from mild to moderate stages of the disease.

One conjecture is those declarative memory deficits frustratingly impact tasks requiring procedural memory. For example, intact procedural memory assists in the sequencing of journeying to the bathroom, taking out a toothbrush, squeezing out the paste, and brushing one’s teeth. Declarative memory kicks in to remember how to open up the PT-recommended walker for the journey, use the OT-suggested foam grip while brushing, and break out the SLP-encouraged Biotene spray after brushing. While procedural memory safeguards all that is routine, there is nothing routine about many of these newly added demands.

What Cognitive-based Interventions are Available?

As medically-based interventions are limited at this time, researchers have focused on studying the capacity of the brain to change through therapeutic techniques. There are two trains of thought that explore the role of neuroplasticity: task-oriented training and cognitive-linguistic training.

The purpose of task-oriented training is to improve affected areas of a deficit with cognitively stimulating activities. The belief is that the skills needed for recall, attention, and problem-solving can be trained and improved upon through the techniques of blocked practice, continuous verbal praise, errorless learning, and intense dosing schedules. These practice exercises–-ranging from complex word problems to story comprehension tasks–are available in the form of computer games, iPad applications, or worksheets. Those who question the legitimacy of these exercises tend to highlight that each task heavily relies on the use of a rapidly declining declarative memory.

In contrast, cognitive-linguistic training pursues the enhancement of ADLs directly, practicing real-world tasks with everyday objects in contextually appropriate environments (Ciro, 2020). This program exercises procedural memory, an area that remains intact for many individuals well into the mid-stages of AD (Zanetti et al., 1997). Cognitive-linguistic training holds clinical efficacy, using practical goal-oriented strategies to improve ADLs and uphold one’s quality of life for as long as possible (Clare et al., 2010). On the other hand, naysayers argue that while evidence suggests performance gains, the effects of cognitive-linguistic training programs are not necessarily attributed to this method alone as it is not yet a standardized practice and other techniques tend to be used alongside it (Martin et al., 2011).

While both types of training require additional testing, cognitive-linguistic training with its undeniable focus on ADLs shows promise for enhancing intact procedural memory. FOX’s Geriatric House Calls™ offer our patients the benefit of applying cognitive-linguistic tasks directly within the home setting.

Which Therapeutic Activities Should be Used for Individuals with Dementia?

A patient’s brain neuroplasticity is impacted by the individualized treatment plan, including environmental factors, the duration of therapy provided, and the number of repetitions introduced. The treatment plan should consider the patient’s current level of abilities and therapy would then incorporate all relevant ADLs.

Imagine a 79-year-old widower named Don. He was diagnosed with dementia approximately three years ago. Recently, Don’s cognitive abilities have notably declined as reported by his 24/7 home health aid, Marsha. A retired teacher, Don’s daily routine now consists of watching the home improvement channel, taking phone calls with his geographically distant family, and enjoying hot meals courtesy of Marsha’s cooking.

Currently presenting with mild to moderate cognitive-linguistic deficits, Don can be introduced to table activities, such as solving deductive reasoning puzzles or playing word games on his new smartphone. However, additional functional activities could be added to his routine, including developing skills for sorting bed linens, clipping grocery store coupons, organizing his mail, washing vegetables for Marsha’s cooking, or engaging in an activity of labeling family members in photo albums.

Cognitive programs with goal-oriented training are based on the most meaningful activities for the patient. It is imperative to practice activities that mimic closely these activities and to repeat them frequently in environments as similar to home as possible. A FOX rehabilitation specialist might utilize the following:

• Rather than performing all activities seated on the formless velvety cushions in the living room, one might try to transition to the dining room to sequence setting a table.
• Encourage Don to join Marsha when doing laundry tasks, such as folding freshly washed sheets.
• Supervise the walk between the bedroom and the toilet, while problem-solving how to efficiently light the hallway for his safety during nightly bathroom trips.
• Encourage Don to sit at the kitchen table to gather his thoughts before he verbally recalls the steps to his morning routine.

How Can Family be included in Cognitive-Based Therapy?

These cognitive-based interventions should occur alongside forming conversations with involved family and caregivers. Marsha could offer support during Don’s efforts to carryover effective compensatory techniques, such as repetition, visual aids, or frequent reorientation to the tasks at hand. Geographically distant family members can be provided with strategies to alleviate any potential frustration as well. Whether applied to weekly phone calls or in-person reunions, strategies such as speaking in 2-3 short phrases at a time, establishing a topic of conversation, and maintaining that topic can be effective in increasing the patient’s communication with loved ones.

Without a doubt, FOX Geriatric House Calls™ allow the opportunity to transform cognitive-training into everyday activities. For satisfactory results, step out of the hallway or gym and into home life.

A MESSAGE FROM THE AUTHOR

The total number of people with dementia is rising and currently projected to reach 82 million in 2030 and 152 million in 2050. In fact, by 2050, it is projected that someone in the United States will develop Alzheimer’s dementia every thirty-three seconds (Herbert et al., 2001). With risk factors such as alcohol use, high cholesterol, and diabetes, dementia is proving to be ever-looming in the future of young Americans.

A survey conducted in 2016 by the CDC indicated that 11% of Americans aged 45 years and older report a subjective cognitive decline, however, 55% of those who report declines do not consult a health care professional. It is imperative that anyone concerned with their cognitive-linguistic abilities consult a healthcare professional.

As an SLP, I have been receiving more referrals lately from individuals recently diagnosed with dementia or with an underlying disease that has progressed to include symptoms of dementia. Although I primarily specialize in voice, swallowing, and language impairments, I have developed strong skills in addressing cognitive-linguistic deficits out of necessity. The topic of cognitive rehabilitation for individuals with dementia matters because of the prevalence and need for more available information regarding possible interventions, to ensure one has the optimal quality of life.

References

Alzheimer’s disease facts and figures. (2018). Alzheimers & Dementia, 14(3), 367–429. DOI: 10.1016/j.jalz.2018.02.001

Ciro, C., (2020). Dementia and Capacity for Learning in Rehabilitation Sciences. [Lecture]. https://foxrehab.medbridgeeducation.com/

Ciro, C., Stoner, J., Prodan, C., & Hershey, L. (2016). Skill-building through Task-Oriented Motor Practice (STOMP) intervention for activities of daily living in dementia: study protocol for a randomized controlled clinical trial. Clinical and Translational Degenerative Diseases, 1(2), 45. https://doi.org/10.4103/2468-5658.184743

‌Clare, L., Linden, D. E. J., Woods, R. T., Whitaker, R., Evans, S. J., Parkinson, C. H., van Paasschen, J., Nelis, S. M., Hoare, Z., Yuen, K. S. L., & Rugg, M. D. (2010). Goal-oriented cognitive rehabilitation for people with early-stage Alzheimer disease: a single-blind randomized controlled trial of clinical efficacy. The American Journal of Geriatric Psychiatry: Official Journal of the American Association for Geriatric Psychiatry, 18(10), 928–939. https://doi.org/10.1097/JGP.0b013e3181d5792a

Hebert, L. E., Beckett, L. A., Scherr, P. A., & Evans, D. A. (2001). Annual Incidence of Alzheimer Disease in the United States Projected to the Years 2000 Through 2050. Alzheimer Disease and Associated Disorders, 15(4), 169–173. DOI: 10.1097/00002093-200110000-00002

Martin, M., Clare, L., Altgassen, A. M., Cameron, M. H., & Zehnder, F. (2011). Cognition-based interventions for healthy older people and people with mild cognitive impairment. Cochrane Database of Systematic Reviews. https://doi.org/10.1002/14651858.cd006220.pub2

Reiman, E. M., Quiroz, Y. T., Fleisher, A. S., Chen, K., Velez-Pardo, C., Jimenez-Del-Rio, M., … Lopera, F. (2012). Brain imaging and fluid biomarker analysis in young adults at genetic risk for autosomal dominant Alzheimers disease in the presenilin 1 E280A kindred: a case-control study. The Lancet Neurology, 11(12), 1048–1056. DOI: 10.1016/s1474-4422(12)70228-4

Unpublished data from the 2015 and 2016 Behavioral Risk Factor Surveillance System survey, analyzed by and provided to the Alzheimer’s Association by the Alzheimer’s Disease and Healthy Aging Program (AD+HAP), Centers for Disease Control and Prevention (CDC).

Villemagne, V. L., Burnham, S., Bourgeat, P., Brown, B., Ellis, K. A., Salvado, O., … Masters, C. L. (2013). Amyloid β deposition, neurodegeneration, and cognitive decline in sporadic Alzheimer’s disease: a prospective cohort study. The Lancet Neurology, 12(4), 357–367. DOI: 10.1016/s1474-4422(13)70044-9

‌Zanetti, O., Binetti, G., Magni, E., Rozzini, L., Bianchetti, A., & Trabucchi, M. (1997). Procedural memory stimulation in Alzheimer’s disease: impact of a training program. Acta Neurologica Scandinavica, 95(3), 152–157. https://doi.org/10.1111/j.1600-0404.1997.tb00087.x