As Cognitive Decline Commences, Here’s How SLPs Can Help Keep the Golden Years Gold
By Abigail Blechschmidt, MS, CCC-SLP
Speech-Language Pathologist
As I sit and reflect on my patients, I realize how often I hear phrases echoing the sentiment, “Oh, honey. Don’t ever get old.” Recently, I even heard, “I was told these would be my golden years. Yeah, right!”
Even when said in the most lighthearted way, I am always stopped in my tracks at comments like these because my thoughts on aging have always been “growing old is a privilege” and “getting old beats dying young.”
My patients bring me back to reality because aging sounds great if everything stays the same. Yet for many older adults that is not the case.
Of course, individuals have plenty of different reasons for feeling that aging is far from pleasant. As a speech-language pathologist, negative feelings of my patients often center on cognitive-communication changes.
Imagine how one might feel if they started making mistakes in a cross-stitching pattern because their memory is inconsistent, or a former accountant who is making mistakes paying bills. Picture a homemaker who is forgetting to change over laundry from the washer to the dryer for several days, resulting in caregivers needing to be involved. Envision a former nurse who no longer manages her own medication because her family thinks she is unsafe.
When cognitive changes become more noticeable, as is common with symptoms of mild cognitive impairment, maybe aging really does start to lose some of its shine. As SLPs we play an invaluable role in helping to bring back the glamour to aging with support in differential diagnosis, compensatory strategy training, and caregiver education. Our combined areas of expertise can improve quality of life.
HOW SLPs IDENTIFY A MILD COGNITIVE IMPAIRMENT
SLPs use differential diagnosis to correctly identify a patient’s needs.
What distinguishes MCI from typical aging or dementia?
Think of cognitive decline as a continuum. Typical age-related cognitive changes occur first. Here, some tasks of daily functioning may take longer to complete, but an inevitable loss in cognitive functioning is not present. For example, watching TV while paying bills may become more difficult. This is divided attention becoming impaired. Another example is short term memory, which in typical age-related cognitive changes means that additional exposure to certain information may be required but the information can be retained. Long-term memory is largely intact at this stage.
Next in the continuum is MCI, which the American Speech-Language-Hearing Association references Peterson et al., 2014, p. 214 to define this stage as an “intermediate stage of cognitive impairment that is often, but not always, a transitional phase from cognitive changes in normal aging to those typically found in dementia.”
One of the key components for identifying MCI is that although cognitive changes are present, overall independence in daily activities is not grossly impacted. Both the patient and other people will begin to notice these changes, so frustration can occur. Some examples of MCI include forgetting appointments or events; increased impulsiveness and poor judgment like giving an excessively large tip at a restaurant, having trouble finding the way around familiar environments (but being able to get there), and feeling overwhelmed by making decisions; planning steps to complete a task; or following directions.
As a point of emphasis, MCI results in more noticeable and more frequent difficulty, but a person’s overall independence remains mostly intact.
The Alzheimer’s Association reports that approximately 15-20 percent of adults over the age of 65 have MCI and around 32 percent of MCI cases will transition into dementia. Dementia occurs when MCI deficits worsen and cause an overall loss in functional independence.
So the same patient who previously would get turned around while walking to the dining room but could correct themselves is now getting lost without the ability to find their way. Changes such as this can be indications that someone is progressing to dementia. Tasks such as writing checks, following a recipe, and planning events cannot be completed. Also, items might be put in unusual locations (i.e., the keys are in the refrigerator) and items or people are frequently called by the wrong noun.
When SLPs use a combination of standardized assessments, informal assessments, caregiver and patient interviews, and observation, we become a part of the differential diagnosis process in seeing exactly how cognition is or is not impacting independence. Our plan of care can then be created effectively to support the patient at their current stage and cognitive abilities. At the stages of MCI, our intervention approach will include development and training of compensatory strategies specific to that patient’s needs.
HOW SLPs’ INTERVENTIONS APPLY TO MILD COGNITIVE IMPAIRMENT
A patient with MCI will benefit from skilled development of compensatory strategies. These will allow them to continue completing daily activities and functional tasks with less frustration and without feeling overwhelmed.
Let’s imagine a patient named Alice. At evaluation, Alice reports that she is writing checks to pay bills for things that are not on auto-payment. She can’t seem to keep her check register log updated. She also manages her medication and usually remembers to come back to her room during breakfast to retrieve a pill sorter that she left behind. Lastly, you notice piles of mail stacked up on her table because she reports that sorting through her mail is daunting.
You come to realize that the checkbook register slots are very small and Alice is writing information in the wrong location. Alice wants to keep up with a checkbook register because then she has confirmation of what bills were paid and checks were written. A strategy in this situation maybe printing out a large-print check register, highlighting required areas, and giving an example line. The checkbook register can then be put in the location Alice prefers to write checks and any written reminders or notes can be included there also.
To assist in remembering to take her medication to breakfast, a visually stimulating sign can be put on Alice’s door: “Stop! Do you have your medicine?” Place this at her eye level or directly above the door handle. Wouldn’t it be nice if Alice didn’t have to make two trips on the elevator each morning and admit to her friends that she again forgot to bring her pills down? I think so!
Lastly, show Alice how to sort her mail using sorting cards such as “trash,” “shred,” and “to-do.” Any time she goes through the mail, put the sorting cards out to help keep Alice organized regarding what to do with each piece of mail.
It’s important to remember that using person-centered language is imperative to their comprehension of the task. If Alice calls the shredder the grinder, then the word grinder should be placed on the sorting card. If she wants a section of mail for “give to daughter,” then include that sorting card. Your intervention will then allow time to practice completing tasks with these supports in place.
Can Alice now fill out her checkbook register consistently? Do you need to modify the approach at all?
If Alice can again feel like she has control over her daily tasks, maybe some sparkle will return to the golden years. When the SLP gives time, support, person-centered intervention, and encouragement based on a patient’s stage of MCI, we are also fostering a valuable relationship to prepare for the likely case that the patient may need our help again.
COGNITIVE DECLINE CAN PLATEAU AS AGING CONTINUES
As mentioned previously, not all cases of MCI will progress to dementia. Many older adults will live their lives out showing the same deficits in cognition with the overall ability to maintain functional independence.
Let’s think about Alice again.
We have supported her checkbook register completion, taking medication to breakfast, and sorting mail, but maybe in several months a new limitation will arise and we will be back to support while still at the stage of MCI.
HOW SLPs CAN INTERVENE WHEN DEMENTIA DEVELOPS
But what about that 32 percent of people with MCI who eventually are diagnosed with dementia?
When SLPs have already established a relationship with the patient and their family members from working together during an earlier stage of MCI, a level of trust and familiarity is built that allows for more effective intervention at the scary time of learning of the diagnosis.
Research indicates that “elderly individuals with dementia will develop psychiatric symptoms within 5 years, which commonly include apathy, depression, anxiety, and, often, combinations of these and other symptoms. Predementia states such as mild cognitive impairment (MCI) feature psychiatric disorders, but less commonly than dementia.”
SLPs who are familiar with the patient in a time of increased confusion, anxiety, and/or depression can become a source of support for the patient and their caregivers.
If we already have a relationship established, beginning intervention during this difficult time is much smoother. The patient can feel like there is some consistency in their life and they have a support system with whom they are comfortable.
Alice would already know me. She knows that I am here to help and find ways to make her life easier. We do not have to start from the beginning, but instead, our relationship is already present. In addition to supporting the patient, SLPs support and educate family members who go through various emotions caring for a loved one with cognitive changes.
MY EXPERIENCE WORKING WITH CAREGIVERS FOLLOWING DEMENTIA DIAGNOSIS
Establishing rapport with our patient’s family members results in greater response to intervention at both the MCI stage but also with possible progression to dementia. As SLPs we know that each case is different from others. One patient with MCI may look completely different from another in terms of their abilities, limitations, expectations, and family support. If we take the time to educate family members on what may be coming and how to communicate with their loved one, that family can physically, financially, and emotionally prepare for the journey ahead.
The other day I was working with a patient with MCI who is new to my caseload. She was telling me about how wonderful her son treats her, but about a year ago he called her and said, “Mom, you need to stop driving and I don’t think you can take care of your dog anymore either.” She verbalized through tears that she still resents him for telling her this information, even though they have a strong relationship.
My patient did not feel ready for this information. She did not feel like she was part of the decision. Even a year later she did not fully understand why both things had to happen at that time.
As her SLP, I agree that this patient is likely unsafe to be driving due to her short term memory difficulties. And maybe her dog would be better taken care of in another home. But what if her son had an SLP as a resource to educate him on the communication strategy of asking rather than telling? How about talking with his mom about these topics rather than giving her the feeling that he had made this decision behind her back?
My patient now has an overwhelming feeling like she is stranded at her assisted living facility because she doesn’t have a car and her son is 4 hours away in another state. What if the son had been guided by an SLP on working together with his mom to establish other options for her consistently getting around, running errands, getting to appointments, going shopping?
Likely, she would not feel like a major piece of independence was pulled out from under her so suddenly. Not all family members and caregivers are able to process what is going on with their loved one, so having education and guidance can result in more success for both the patient and the family member.
SLPs play a critical role in the support of patients with MCI, whether it is a recent diagnosis of MCI, a long-standing diagnosis, or the unfortunate progression from MCI to dementia.
We need to globally assess our patients to provide differential diagnosis and therefore a person-centered and functional treatment plan. SLPs also give support in the establishment and training of compensatory strategies and education of caregivers and family members to be prepared support systems.
Finally, involvement in care at the MCI stage enables rapport to be fostered so that later involvement is effective. If we can supply our patients experiencing MCI, who are going through the ups and downs of aging, with ways to feel more like themselves then the golden aspect of the golden years has the best chance to remain. Because after all, aging is indeed a privilege that only the lucky get to experience.