EXAMPLES OF THERAPY STRATEGIES FOR DEMENTIA PATIENTS (from A. Price)

1. QUESTIONNAIRE/INTERVIEWING: Family, Friends, Social Worker for information to aid in designing therapy strategies (.Example:• Memory•book, Milieu Therapy...Bourgeois has a Memory Book information form).

2. TIME LINE: (Pictures, event descriptions, etc., of the 1800's and 1900's to identify items of interest, eras, people, music, etc., to include in resident's memory book or to elicit conversation etc.•




3. INTERNAL MEMORY SYSTEMS: (For  milder dementia)
Example: Circumlocutions, first letter cuing.


4. EXTERNAL MEMORY SYSTEMS:  Memory Notebooks containing family tree, nam s, dates, places (Bourgeois has a detailed description), calendars, watch, schedules, timer. Signs (example: to help them recognize their room, to label important items in drawers/closets, to supply names of objects in room.  Diary/sign-in book: Visitors, therapi-s-ts,•or-other facility •-  staff  write  date,  time  and  a  brief  description  of interaction/activity. that they did with-resident. When people come in, they can review this information with the resident, converse about it, then add information about their encounter.

5. MILIEU THERAPY:  Environmental manipulation can affect quantity and quality of communication:   increase familiar stimuli and decrease unfamiliar stimuli (Example: rearranging furniture to be more like a home, adding plants, familiar pictures, decorations, bedspreads, having a tape recorder with tapes of familiar music in room.
'  .  .. .
6. PAIRING ACTIVITIES: To encourage carryover to therapy techniques.
Example: Ask CNA to go over calendar and daily schedule on wall every
time-they make resident's bed as demonstrated by you.

7. BEHAVIOR MODIFICATION TECHNIQUES: Rein.forcing of appropriate speech/behavior, ignoring of inappropriate behaviors.

8. SIMULTANEOUS BUILDING OF ADL AND COMMUNICATION SKILLS: (OT &  ST usually . do this together with an individual or small group).. Example: 2-3 step activities involved in making a food item, getting to•the dining room,
etting dressed. Items are named, steps sequenced and verbalized, types of cuing needed are determined.


9. STRATEGIES DESIGNED TO INCREASE ATTENTION:
verbal/visual reminders, holding hands, etc.

Such as timers,


10. IDENTIFICATION'/TRAINING OF COMMUNICATION BUDDIES: May be another resident who will feel good about h lping dementia patient.

11 .. ENHANCING  COMMUNICATION SKILLS OF THE RESIDENT IN THE ACTIVITY PROGRAMS:
••••-May start with activities director, resident and speech therapist and
-progiess to small activity groups, stressing techniques that worwith this resident. May require several sessions of demonstration and observation.

12. VALIDATION' THERAPY: To make valuable- he-reality theresident presents
(See handout).

13. REMINISCENCE THERAPY: .(also called life review) encourages  recall. of
-past (see handouts). -

14. Give instructions one step at a time and break activities  into several steps. For example, the instruction: "Put the sugar in your coffee", can be broken down into several steps. 11Take the spoon. Put _the. spoon in the sugar•. Fill the spoon with sugar. Add the sp.oonful of sugar to your coffee. Stir the coffee with the spqon. Take the spoon out of the coffee. Put the spoon on the table. Drink your coffee.."

15. When  communicating  verbally  with the resident  is difficult,  train staff/family in nonverbal  communication technigl.res inclu.din-g -touch, gestures, facial.expression, voice tone, body posture.   (See section from Theraneutic  Activities  with  Persons   isabled  bv  Alzheimer's Disease.

16. Speech and occupational therapy should work with the activities director in setting up a sensorv stimulation group to enhance attention, verbal and nonverbal responses, etc.  (See sensory stimuiation information from Therapeutic Activities with Persons Disabled bv Alzheimer Disease.


Long term goal: MAXIMIZE EXPRESSION OF  Language •


Short Term Goals:

1. With cuing the patient will
(visual, verbal, multi-)

repeat ----------------------- pertaining o environrnent
(words, phrases)

after speaker with ------.ac.curacy.


2. The patient will utilize automatic speech {i.e. social greetings, singing, stating name, etc.) with
  cueing from clinician/staff/family.
(min. ,  mod. ,   max. ) ---


-3 •• The patient wlll utllize• sp taneou. s speech (i.e. needs, desires, key information, etc.) at the  
(word, phrase,sentence
mQ.,lti-scntence)

level with cueing from clinicianjstaff/family-.-
(min.. , m d. , max.)

4. A. To determine the patientis functional vocabulary.

B. To instruct staff/fam ly in interpretation and use of patient's functional vocabulary.

5. _With cuing  the  patient  t-;i _l   name  
(min. , mod. , max) (objects, _labels,_••
items in:acate.gory)
within their environment.. ......   _
- - .- - -..  •--   - .



6. A. _Through   use of comp nsatory techniq_ues the

-



rr. . MAXIHizE••  COMPREHENSION.
- OF   LANGUAGE:


.. : ....•.• ....: - ...










  % accuracy.


..•• .... ;••.....
. .   ..•.
'  -•



2. With cuing thp tient.will match functibria
(visual, verbal, multi-) -


objectto with   (object, picture, within a category)

....._

% accuracy.

3. Hith  

cuing the patient  v:ill  rcco•gnize verbal­

(visual,  verbal,
.... . .  --

multi-)

labels-by with %     accu  u_c•y.
(naming, pointing focusing, gesturing, etc)


- 4. With cuirig tha patient will follow simple
'""  (vis_ual,• verbal, multi-)

verbal commands  pertuining••f; • ,• .,., ith
(body parts,  environt tcnt.:.'ll  objects)


   !t  accuracy..
s. With -....;..-.._.-- _ cuing the





patien




'•
t will respond to e= a:


yesfno questions through with
(head nods, gestures, vcrbol response)

accuracy..

6. With cuing the patient \•Jill rcspcr-.d to  audi o:::y

(v.i.sua.

, verbal, multi-)


factual information questions/directives relating to

  with   %•    accuracy ...
.•- immediate environment,
general environment,
recent events, needs)

.:...


.....•.- - .. .•  . .. .•..• .._ ...




. -;-.


MAXIMIZE"" COGNITIVE LINGUISTIC PROCESSES



• ..... .

.. ••.....   -   .

. ."•:. .:-.•-•• - .••. :;: i.. -:._:.:,_•;•.. ..



1..

The   pa:tient will  attend  to task/activi i '!O':fo::• <ln::: - "fi t:;=:-.
0        -.•... •••• •• -'•--:.:- •• :
tim-e. frame  with. . cuin•g by   clinic:an:f

(.verbal,_

tactile,.

visual,  mu ti) • •• •. • •


staff.



-•----.. 2.

To  instruct staff/family in use of  compe satory st 4ttegies• for

maximizing conversational skills (i.e.sustainig topic, turn

..taking,   eye contact,   etC:) -:-



3. To'  instruct  staff/family  in ..use  of   reality-ericr.t tion techniques (i.e. validation, consistent vc::-bal respcnse, etc.)
to  minimize the patient's  confusion.



4.






















•-- -- --

-•
To  instruct st.aff/f mily ip..use of   compensatory strategies  for
"     •.  .
maximizing the  patient's left - to - right isual field orientation .











....



"r-'
--

0       0      •     ••

----- - -

CAPABILITIES PROGRAM
SPE-ECH AND LANGUAGE GOALS
,

. LONG-TERM GOAL:.
....

Identify cognitivejcom.municative limitationsanddeficits which reduce functional ability. • • •' •


SHORT-TERM GOALS:


AdmiJtister .tests• or batteries:- e.g_• IDEA Battery, Ro_ss Information Processing Assessment(RIPA}, riz.ona Battery for commun"lcation•Disorders:•(.ABCD). (Also included would be information from• family members, apabilities Clinical Examiner, staff.)


2. LONG-TERM   GOALS:  Develop external memory system to maximize resident's functional communication skills.

SHORT-TERM GOALS: - Create personal history notebook of significant persons arid events.
- DaveLop calendar for events, important dates, schedules, time concepts.
- Label objects, tasks to cue resident for -
particular action, in facility and in
resident's room.

3. LONG-TERM GOALS: Identify distractions _present and develop a plan for controlling environmental stimuli to reduce language comprehension difficulty andjor reduce episodes of confusion.

SHORT-TERM GOALS: - Instruct caregives regarding hypersensitivity o•f re'sident to background, extraneous or inexplicable sounds.
- Give caregivers_ pecific nstructions for reducing stimuli.n environment e.g., radio, T.v.,• hallway activity, competing conversations, etc.

4. LONG-TERM GOALS: Develop a plan to address reality orientat on issues.

SHORT-TERM GOALS: - Develop a plan to provide consistent verbal response to resident's confusion and/or lack of reality orientation.. (e.g., regarding spouse's death, current year, etc.)
- Instruct caregivers in appropriate use
of reality orientation and alternatives - such as validation in the presence of • severe memory deficits.

-



- j. LONG-TERM GOAL:

Identify  stimuli  and  situations  that -  trigger inappropriate-behaviors (sexually aggressivef..".obilOXious behaviors[ in order to develop consistent communication
1:esponses to reduce those behaviors.-       . .:;..;";•- :.::.:::-:::•  •
.  ---.; •   ...•.- •..


SHORT-TERM GOALS:

-Instruct caregivers to totally ignore•
the behavior in order to extinguish it.
-Instruct caregivers to respond with
simple reprimand/direction: e.g.
"Stop, John."
- Instruct caregivers to respond by
redirecting the residene in a specific
way.


•: -••-•  .


6. LONG-TERM GOALS: Develop  a plan of response to  decrease resident's perseverative behavior and train staff to follow through with and  develop-•... understandingjtolerance  of- .these behaviors.

SHORT-TERM GOALS: - Educate caregivers regarding patient's
-inability to inhibit and/or control
repetitive verbalizations.
- Train caregivers in appropriate verbal
responses to reduce anxiety and with­
drawal behavior.

7. LONG-TERKGOALS: Develop a plan of response to reduce episodes of abusive language.


SHORT-TERM GOALS:

•           .... #

- Dev.elop a communication strategy for direct confrontation with the resident.
- Develop an alternative strategy to ignore the resident'verbal  behavior.
- Develop a reward system to eliminate the-behavior.
- Train caregivers in appropriate communication strategy to manage
•andfor reduce the behavior.


8. LONG-TERM GOALS: Develop communicative plan of response to reduce patient's inappropriate wandering.

SHORT-TERM GOALS: Teach staff to identify appropriate marked walking path for resident.
Teach resident and staff  to use a. meaningful external memory symbol (e.g.,larg TOE sign)  to eliminate inappropriate wandering.

•--- ---- - ...._

.....


..









Teach resident and staff .to use  a meaningful externamemory   symbol (e.g.,• a large GO: signt.to increase resident  participation  •in : SJ?.ecific
activities or locations.            ••.• •?..:.-:,<:.: .•'


9.-L.O_NG-TERM GOAL:

•••    -    ••      0   ..

Develop   a   communication   response  :• •and ..•. ;• teach staff/caregiver to use the response consistently• to decrease  res1dent•s'•   rummaging- in -otner- resident's belongings.



SHORT-TERM GOALS:


- ----...

- Teach staff/caregivers effective communication strategies to redirect resident to appropriate activity. Teach staff/caregivers and resident to use meaningful external memory symbols (STOP sign) to eliminate inappropriate rummaging.
- Teach staff/caregivers and resident to use meaningful external memory symbols (GO sign} to encourage appropriate (structured} rummaging activity.


10. LONG-TERM GOA : Develop most effective communicative approach to increase participation in social events.


•• SHORT-TERM-GOALS:










11. LONG-TERM GOALS: SHORT-TERM GOALS:

- Teach staff/caregiver and resident to use external memory aids to increase attendance at fun ions (signs, personal invitations immediately before).
- With caregiver's assistance, .assign a
"communication partner" to resident to
i.ncrease-participati h.in functions.

Define and develop most effective commu.n-1czation strategy to be used with resident to increase participation in ADL's.

- Develop with OT and caregivers, calendar/time chart resident's schedule•. Develop specific verbal, visual, or gesture instructions to obtain maxima resident response.
Teach caregivers the importance of using these consistent instructions with residents.

--
•-- ---- - --






-•.. •-.-...:- ..     . ...

..... •. ••....• .•
L2.  LONG-TERK GOAL:Develop most effective communication  appr?ach:. o.•_elic•it
"Tncreased verbal responses. .. ...•..:: -.-•••t:}'.;::/•:..


SHORT'-TERM GOALS:.

Provide caregi.ver with communica:tio ;•••:...:/.:l.7 > Cs  /.:•• nstruct ons nclud ng• demonstrat.Lon •..:-••..••.. F: .> for cueing resident•.. :  • • .::••.-: :-:.'• ::.•• Teach caregiver to offer verbal,: visual •• . :. •
and tactile:stimulation••dur:i:ng every• • •...,
contact with resident.
Teach staff specific communication
strategies to obtain specific
communication responses from resident.
(e.g., This needs to be resident specific..) -


13. LONG-TERM GOAL: Develop appropriate communication strategy to increase resident's abiLity to_cDmplete tasks.

SHORT-TERM GOALS: Develop cue structure that will keep resident on task. (e.g., Monitor instructions being given and
resident's completion of each task.)
- Teach caregiver resident sp cific cue structure. (e.g., Break down instructions so that resident can follow specific task - 11put on your blousen rather than "get dressed.") Provide in-service. and teach caregiver importance of using cue structure hat will keep resident on task.

14. LONG-TERM GOAL: Develop stimulus materials andfar strategies to achieve maximum functional communic tion ability.

SHORT-TERM GOALS: create a memory notebook for reference including in it significant historical personal events (develop with family), names of family, friends, caregivers, important dates, etc.
Provide family members with literatur
on the nature and course of Dementia including coping strategies to improve
their communication relationship with resident.
. .
15. LONG-TER11. GOAL:Enable resident to communicate information• about their personal history and relations with caregivers..

--





...

SHORT:-.TERM GOALS:

ereaee• a memory notebook with pictu;; -:.:..•..• :. of significant persons. (To baused:.as:••• •::_.•:..,..
an external m mory ai<?- to rigger .: : .:  ?.;.• -•.-• .<•••. •
recall. of namesjrelat onsh ps or- to•,:•-=  -- : £}:..:.•_. ? .': ­ inc1ude names and relationships• •for • ::••.:. ::>_:•.. ::• •  . recognition of  such, and provide.a•;:.;.:..
topic for interactive communication-t•••:••.:•. ••.-••.
Teach caregivers to identify themse ves'•.•.•. •:
by name and relationship on each. ••• •
contact with the resident. Develop a life revlew diary with resident (and family,) and teach caregivers to review and discuss it with resident regularly.


16. LONG-TERM GOAL: Enable resident to communicate their personal needs• to caregivers.  

SHORT TERM GOALS: Establish effective com.mun•ication response system for resident. Establish a communication board of pragmatic needs (e.g. glass/thirsty, fan/hot, blanketjcold, nursejcall button, phone/family contact.)
Teach caregivers use of communication system designed for resident.

17. LONG-TERM GOAL: Develop plan to assist resident to adjust to and cope with daily routines (particularly appropriate for new admissions.)

SHORT-TERM GOALS: - Develop effective strategies and stimulus materials"t9 teach resident the schedules and locations of important functions (e.g., resident's room, meals, activity room, etc.). Teach caregivers to consistently use these strategies and materials with• resident to establish routines.

18. LONG-TERM GOAL: Instruct resident, family, and/or caregivers in the
-appropriate strategies to facilitate and maintain. maximum functional ability.


SHORT-TERM GOALS:

- combine appropri te go l.s from above•-• .







.'



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