Functionally Addressing Cognitive Impairment

Alexis Streetman MS, CCC-SLP: My grandfather died from complications of Parkinson’s disease. He is actually the reason I became a speech pathologist. I think that if the rehab-sciences had been involved at the end of his life, he would have had a much higher quality of life. He would have lived longer, and he would have been healthier.

Dr. Jimmy McKay PT, DPT: Welcome to FOXcastSLP, a podcast for clinicians, made by clinicians. It’s brought to you by FOX Rehabilitations. Find out more at foxrehab.org.

Dr. Jimmy McKay PT, DPT: Welcome to FOXcastSLP I’m your host Jimmy McKay along with a colleague on the program this afternoon Alexis Streetman. Alexis welcome to the show.

Alexis Streetman MS, CCC-SLP: Thank you so much for having me.

Dr. Jimmy McKay PT, DPT: Let’s see where are you calling in from?

Alexis Streetman MS, CCC-SLP: I am in Charleston, South Carolina.

Dr. Jimmy McKay PT, DPT: I am jealous.

Alexis Streetman MS, CCC-SLP: You should not be because it’s 100 degrees here.

Dr. Jimmy McKay PT, DPT: I have a rule you can complain about one temperature extreme. I complain about cold, so I could I could get used to Charleston pretty quick.

Alexis Streetman MS, CCC-SLP: Fair enough.

Dr. Jimmy McKay PT, DPT: That’s that’s the thing though with this practice. 16 states with FOX Rehabilitation and growing. You know I’m in New York City right now and South Carolina is where Alexis is located. But we’re colleagues.

Alexis Streetman MS, CCC-SLP: True story. It’s great. I really love having colleagues kind of all over the country because problems I see here are sometimes unique to this area and it’s really interesting to be able to talk to colleagues elsewhere and I’m kind of like hey I’m seeing this thing here and they’re kind of like yeah that’s not an issue here but this is the issue here. And then there are some things that are universal.

Dr. Jimmy McKay PT, DPT: Yup. So today we’re talking about functionally addressing cognitive impairment. What’s that mean to you. How would you sum that up.

Alexis Streetman MS, CCC-SLP: When you think about cognitive impairment. It is the decline of cognition. Obviously that’s the definition of it. But how does that affect you in your day to day. I want to talk a little bit about how cognitive impairment affects people day to day whether it’s mild-cognitive impairment or late-stage dementia and how to functionally address those deficits that people have and what they perceive their deficits to be.

Dr. Jimmy McKay PT, DPT: Sounds good right? So where do we start what’s the client’s perception of their deficit? How do they actually view what’s going on with them?

Alexis Streetman MS, CCC-SLP: I think that this is probably the key to addressing cognitive impairment with anyone. What the patient sees as their biggest problem is actually the biggest problem. And for some of my patients they’re kind of like you know I’m just not as sharp as I used to be. You know maybe I have a hard time remembering conversations that I’ve had with people or the other day I just got to the grocery store and I walk down the aisle and I just couldn’t remember what I wanted and so I walked away and then I remember and then walk back on the island still can remember. So it’s working on the things that people see as their actual deficit. There are a couple of reasons why that’s so important. And the first is that motivation is the big thing. If someone is motivated to work on what you’re working on with them they’re going to do it when you’re not there. And the other part of that that ties into carryover of the strategies that you teach people in therapy and some of the strategies that I give people are electronic on cellphones or you know mobile devices and some of them are pen and paper because our client base is diverse in a lot of ways. I think the youngest person I’ve ever worked with is age 36 and we worked on a lot of electronic strategies with her and for her her cognitive impairment was a brain injury but then I have some clients who are 94 years old and they’re kind of like well I don’t use my cell phone for anything ever except for maybe an alarm clock. So we need to stick the pen and paper strategies for them.

Dr. Jimmy McKay PT, DPT: That just shows your adaptability not knowing exactly what we’ll address you know that person’s impairment in the best way possible.

Alexis Streetman MS, CCC-SLP: And I think that a lot of times soapies forget it. We have a really large tool kit to pull our tools from not just like workbooks that we can get our tools from it’s also things like password management software which I actually want to talk about in a little while because it’s that is I think one of the most important things for us to talk about with our clients is passwords. We’ll talk about that in a minute. OK. All right what do you want to go next. So caregivers really need to be involved in this. Caregivers will often be your greatest assets in treatment because they see things that you don’t see day to day in therapy. I have had clients that I worked with in the past and there currently are. There’s nothing wrong I am just fine. And then the caregiver will kind of pull me aside and there will be like actually mom wanders out of the House and our neighbors find her and she doesn’t know where she is or how she got to the house and we really need some strategies to help her understand that she can’t go wandering at 2 o’clock in the morning in bare feet. They will also be able to tell you which strategies do and don’t work. That is a key component to working with clients with Congress. The impairment is really making sure you involve caregivers not only in asking them what deficit they perceive but also in hoping you identify which compensatory strategies you’re using or which intervention methods that you’re using work and which ones don’t.

Dr. Jimmy McKay PT, DPT: Developing a great relationship with the caregiver is integral. I mean there are going to be a great way to extend your care they’re going to see things that you don’t see on a regular basis and they’re going to be able to help you implement the things that you want done. You know the other 167 hours of the week when you’re not there.

Alexis Streetman MS, CCC-SLP: Exactly. That’s exactly what caregiver’s was so important for. There was a really interesting study that I read recently. It’s by Chieng from 2017, and it was actually talking about dementia-caregiver burden and I think that this is also something we really need to address as speech pathologists. We don’t think of ourselves sometimes as being involved with activities of daily living. But if I have a client that I’m seeing who gets agitated every single time it’s time for them to take a bath or shower I need to figure out where the breakdown is because the behavior that they’re exhibiting with this radio is distressing for their caregiver. So if I’m working with a patient and we’ve been working on sequencing for other tasks it might be worth it for me to come up with a visual aid or with some sort of verbal cue that the caregiver can use with that client so that they know OK it’s time for us to take a bath. My caregiver is going to have to help me get undressed they’re going to have to help me bathe and then they’re going to have to help me get dressed again. So I had one client that I worked with who it was a simple checklist that we laminated and we hung it on her bathroom mirror and as they were going through her Agios she checked off what she had done so she could remember what she had done. So she didn’t get agitated during the completion of those tasks.

Dr. Jimmy McKay PT, DPT: That’s a great insight. I love that. Where do you want to go next?

Alexis Streetman MS, CCC-SLP: What does everybody else see? You know so what does the client see? What is their deficit? What does the caregiver see as the deficit? What do other people see? What does physical therapy see? What does occupational therapy see? What do friends and family members who aren’t in the day to day see? Is the deficit a sequencing deficit where occupational therapy is like I am having the hardest time getting them to figure out the steps to brush their teeth. They’re able to do it because maybe their fine motor is OK but we just are having a really hard time getting this. You think you can work on breaking down individual tasks into steps and going through those individual tasks so that they can complete them as part of their ideals. And I did have someone who is goal was to be able to sequence what he needed to do in the morning. So it was going through space retrieval and early learning and some handover had help with that so that he could work on those ideals. So it’s super important to know your occupational therapist your physical therapist and really have a good relationship with them and I feel like I’m so lucky because I have the best colleagues in Charleston. That’s great. And you know on my side I was not trained to do transfers and graduate school that’s not really in my scope or practice and really do transfers by physical therapist that I work with. We talked a little bit and I said hey I really need this person upright in order to work with them. And she said okay well I’ll show you how to do a transfer with this person so that you’re able to get them in the position that you need them in so that you can work with them. So that’s part of that relationship too is there a lot of things that I don’t know and a lot of things that I’m not trained in and I will always say you know what I don’t know. But I usually try to ask my colleagues to make sure that I’m getting the perspective that they can offer me about that.

Dr. Jimmy McKay PT, DPT: I’d love to hear that Alexis. Where we want to go what your final what your final take home for the audience today?

Alexis Streetman MS, CCC-SLP: I’m going to go back to that password thing that I was talking about earlier. I personally use a password software called lastpass. It is one master password and my password is like an entire sentence. That’s really easy for me to remember. But that password because I have last pass enabled it auto fills the passwords for all the other websites that I use regularly. I need them so. I mean this is amazing because I literally log into last pass and I enable it on certain websites and it just articles the passwords for me. So it takes the cognitive load of remembering like the passwords off of me and reduces it down to one password that I have to remember.

Dr. Jimmy McKay PT, DPT: I was having this conversation with someone yesterday and I said my passwords are very very very good at keeping me out of the things I need to get into mostly.

Alexis Streetman MS, CCC-SLP: Oh yeah totally. And happens a lot with people where they’re kind of like I have recent my password for this one Web site like 50 times. And there are 10 passwords that I use but I can’t use any of them because I’ve already used them and the website has me locked out on that password and I just need to figure out how to set up a password for this website. Lastpass also allows you to auto-generate passwords that expire after a certain amount of time and then it auto-generate a new password for you. So there’s your protip through the day last pass is my jam. I love it. I recommend it all time.

Dr. Jimmy McKay PT, DPT: Love it.

Alexis Streetman MS, CCC-SLP: Next thing that I actually really wanted to talk about is something that we always think about as professionals and that is actually making sure that our patients don’t get dehydrated and giving them strategies to make sure they’re drinking enough water. I had one patient in particular whose doctor said you have to drink a certain amount of water every single day. What we ended up doing is we measured the amount of water that was in his water bottle. And then I created a chart for him to hang on his refrigerator was right above where he filled his water bottle and he just checked off every time he filled up this water bottle. So he knew how much water he’d been drinking during the day. Those visual aids are super important and for him a digital water management system wouldn’t have works. So having a visual aid that was on his computer and again it was just a laminated sheet of paper and he just checked it off and then erased at the end of the day.

Dr. Jimmy McKay PT, DPT: Wow. So a lot. That’s great.

Alexis Streetman MS, CCC-SLP: It is important to use things like space retrieval for rules for safety. One of my clients she says she doesn’t have anything going on but she has walked outside barefoot at like 2:00 in the morning and neighbors see her and it’s become a problem for her and her caregiver. So what we have worked on is space retrieval for her recalling that she’s not supposed to go out without anyone else and we have also worked on making sure that she has visual aids in her environment. So she has a stop sign on the back of her front door. That has a written reminder that she has to have some with her before someone with her before she goes outside and then if she’s going outside she needs to make sure she’s wearing shoes. And this is that crossover you were talking about because occupational therapy also does medication management. But I also do some medication management with my patients if that’s a need I have loaner medication boxes that all give my patients and I have probably three or four of them because what I’ve found is one medication management system for one client won’t necessarily work for another client. So one of the ones that I have has individual days that pop out and that’s really great for my clients who are active in the community still because they can just take the day’s worth of medication with them when they go out and that’s great for them especially my Parkinson’s clients who need their carpeting will have a job on time. Every single time so they have that pop out day medication box in a pocket or in their bag and then a lot of times they actually have alarms like we set up alarms on their phones that will go off when their sisters take their medication and they can just take their medication at that time. The last one I wanted to talk about and this one is actually this has been my thing recently. I’ve had a lot of clients recently who have told me they have a really hard time dialing the phone. We have worked a little bit with errorless learning and space retrieval training for remembering phone numbers for significant communication partners friends family members maybe children that live in another state. That’s another thing that I have seen be really successful with my clients. Those are some. All right. And I did want to give a shout out to a couple of organizations or special interest groups that have amazing resources if you have more questions. We like sharing resources. All right. So the first one is the Academy of neurologic communication disorders and sciences and they have a board certification that is specifically for neurologic communication disorders and they have amazing webinars they have amazing continuing education. And like some of the giants of the speech world are involved on boards there. So if you’re interested in aphasia if you’re interested in any other neurologic communication disorder it’s available usually on her website.

Dr. Jimmy McKay PT, DPT: Cool. Love that.

Alexis Streetman MS, CCC-SLP: The other is seriously I love being a member of the special interest groups that I’m a member of. I’m a member of the dysphagia special interest group the Jerian Talagi special interest group and the mineralogical communication disorders special interest group those special interest groups are great because every day they send out a daily digest that clinicians will submit questions about whatever’s going on on their caseload and people always respond and they’re always super helpful or they’ll refer you to research. There’s a lot of really great information that eking out from the social interest groups.

Dr. Jimmy McKay PT, DPT: That’s killer thank you for sharing that Alexis. We love it. Final part of the show Alexis is your FOXtail. Why did you start working with older adults?

Alexis Streetman MS, CCC-SLP: So I might cry a little bit when I say this. My grandfather died from complications of Parkinson’s disease and he is actually the reason I became a speech pathologist. I think that if the rehab Sciences had been involved at the end of his life he would have had a much higher quality of life. He would have lived longer and he would have been healthier. My granddad was absolutely kind. I did not expect to cry today, thanks Jimmy. My granddad was the light in my world and he was the embodiment of the American dream. He raised two girls. He was married to my grandmother nine years. The running joke in my family is that it was my grandfather’s first grandson. Even though I’m obviously not a boy. So anyway so I got into speech pathology because I thought that it would lead to a better quality of life for my grandfather when he was declining from Parkinson’s disease. He had dementia associated with Parkinson’s disease and I think that if he had strategies and my strategy is our family has hired some help with what was going on with him it would have made his life better. And I think physical therapy and occupational therapy also would’ve made the quality of life much much better at the end.

Dr. Jimmy McKay PT, DPT: Well hey I’m glad you’re out there working with older adults and you’re with our practice and I know the families of those older adults you could interact with. Glad you’re there as well.

Alexis Streetman MS, CCC-SLP: Thank you very much. I really appreciate that.

Dr. Jimmy McKay PT, DPT: Thanks for listening to FOXcastSLP, a podcast for clinician’s made by clinician’s it’s brought to you by FOX Rehabilitation.

Dr. Jimmy McKay PT, DPT: Find out more at foxrehab.org.