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Principles of Intervention and Treatment

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Title: Principles of Intervention and Treatment


1
Principles of Intervention and Treatment
2
Treatment Planning
  • Given our current knowledge about mechanisms of
    neurological recovery and language processing,
    three clinical principles should guide treatment
  • Emphasize the positive. Use personal,
    communicative, and linguistic strengths in
    goal-setting and treatment methods.
  • Focus on functional outcome. Adapt treatment
    content to personal interests, background, and
    goals.
  • Respond to patient and family feedback. Change
    treatment goals and methods through continual
    reappraisal of patient responsiveness.

3
Treatment Planning
  • Recommend communication treatment for all
    patients with aphasia, at least on a trial basis.
  • The rationale underlying aphasia treatment
    oriented toward an individuals strengths and a
    positive recovery outlook is not designed to
    foster denial but to inspire the person to muster
    all available personal resources to fight the
    hard battle of aphasia rehabilitation that lies
    ahead.
  • Base treatment on mutual goals set by the patient
    and his/her family, as well as by the functional
    outcome needs of the individual and the family
    nucleus.

4
Treatment Planning
  • For those with right hemisphere syndrome,
    recommend treatment to improve communication,
    cognitive, and perceptual functioning.
  • Because recent evidence suggests that language
    processing in the brain involves several
    processing language in parallel rather than in
    sequence, a more effective method of targeting
    language and communication goals would be to
    stress multiple language modalities through
    functional tasks instead of traditional
    modality-specific tasks, that are stressed in
    sequence.

5
Selecting Treatment Goals
  • After completing an initial diagnostic
    assessment, the clinician compiles a list of
    communication or language skills that testing
    reveals have been impaired, as well as those that
    testing, informal probes and family input
    indicate the individual has maintained.
  • Plot the patients relative strengths and
    weaknesses on a graphic modular aphasia profile.

6
Selecting Treatment Goals
  • Using the modular profile, share the information
    with the patient and family and use the map to
    target treatment goals and select treatment
    stimuli.
  • It is generally best to target a midrange ability
    level for treatment goals.

7
Selecting Treatment Goals
  • By setting communication goals and using
    procedures that incorporate intact abilities, the
    aphasic person can begin the treatment process by
    succeeding.
  • Although aphasiologists have long stressed the
    importance of using functional assessment and
    treatment strategies to maximize the aphasic
    individuals performance in real-life situation,
    the vast majority of SLPs still rely heavily on
    standard published workbooks and programmed
    materials.
  • Functional treatment approaches need not take
    excessive preparation time if family members are
    included in the treatment team and are encouraged
    to select and adapt materials that respect the
    patients vocational or avocational interests.

8
Developing Functional Outcome Goals
  • When developing functional outcome goals and
    treatment stimuli to reach these goals, three
    issues need to be considered
  • Active intervention in the environment.
  • Gainful employment or avocational interests.
  • Social contact/interactive stimulation.
  • Before initiating a treatment program, the
    clinician should identify the interactive
    routines and needs of the family, including
    family dinners, social gatherings with friends,
    religious celebrations or weekly attendance at
    church or synagogue, and eating out.

9
Developing Functional Outcome Goals
  • For many clients with aphasia, real events in
    family life make the best material for practice.
  • Each interactive session should be planned in
    advance, determining who the participants will
    be, where the interaction will take place, and
    the goal.
  • Events can be staged and then practiced through
    group sessions and trips, actual in-home
    treatment with family members present, and role
    playing.
  • Examples of this kind of therapy would be
    planning a picnic with friends, discussing a
    family reunion with other family members,
    conversing with a spouse on a trip.

10
Developing Functional Activities
  • Burns (1996) reported on a client who became
    concerned when he attended a gala banquet and had
    difficulty following the conversation at a large
    table.
  • To prepare for the next similar event, his wife
    and two of her friends joined him to practice
    conversing across their dining room table.
  • As he experienced difficulties, he and his wife
    tried to determine which aspects of the situation
    posed the greatest problems.
  • They then worked together to find a solution.

11
Developing Functional Activities
  • The client learned from the experience that he
    was very dependent on lip reading and eye contact
    to aid comprehension.
  • Consequently, he learned to make a conscious
    effort to directly attend to each new speaker.
  • After practicing this a few times at home, he
    attended the next event and found that his
    comprehension had improved markedly.

12
Developing Functional Activities
  • Another good source of clinical material comes
    from the patients own vocational or avocational
    background.
  • Not only are materials related to previous job or
    interests more motivating because of their
    familiarity, often they present a means for
    easily tapping into the individuals premorbid
    strengths and interests.
  • As long as clinicians are careful to adapt the
    activities to the persons competence level,
    these types of activities provide incentive and
    optimism that at least some level of prestroke
    functioning can be reattained.

13
Developing Functional Activities
  • Another case offered by Burns (1996) was W.A., a
    62-year-old female former secretary with a severe
    Brocas aphasia.
  • She had been an avid bridge player before her
    stroke but all therapeutic attempts to rekindle
    this skill had been unsuccessful because her
    symbolic memory was too poor to remember previous
    hands played during a game.
  • She was very upset that she could not again play
    bridge, but since card playing was important to
    her, her husband decided to try similar games.

14
Developing Functional Activities
  • Soon, with a few adaptations, she was able to
    play hearts and canasta, and in time the two of
    them resumed card parties with friends.
  • The person with aphasia is most often the best
    judge of whether techniques, procedures, and
    goals are appropriate and effective.
  • When the client seems frustrated or progress
    seems minimal, the SLP should change treatment
    goals and methods and continually reappraise the
    patients responsiveness.

15
Developing Functional Activities
  • Patient and family feedback are powerful sources
    of information and fresh ideas.
  • So remember, to change goals when you, the
    client, or a family member discovers new areas of
    interest or need and
  • Continually experiment with new methods for
    reaching long-term goals more quickly.

16
Treatment Guidelines for TBI
  • A two-stage pattern of cognitive and
    communication recovery typically occurs following
    TBI.
  • First the brain heals itself, and a certain
    amount of improved functioning occurs
    spontaneously.
  • Dramatic changes in cognitive and physical
    functioning may occur during the early stages of
    recovery from TBI.
  • During this period, many individuals do not have
    adequate attention and/or stamina to participate
    fully in the assessment or treatment process.

17
Treatment Guidelines for TBI
  • During the initial recovery period, informal
    assessment should occur on a daily basis as part
    of intervention sessions.
  • Later, when the individual has emerged from
    posttraumatic amnesia (PTA) and can participate
    actively in a variety of activities, the second
    stage of recovery begins and the SLP should
    perform a comprehensive evaluation of the
    functional impact of cognitive-communication
    impairments on a survivors life.

18
Treatment Guidelines for TBI
  • At this time, persistent areas of impairment and
    their functional impact on an individuals
    participation in daily activities becomes
    evident.
  • Periodic reevaluation may be necessary for an
    extended time period post-injuryoften for
    several years.
  • Because of this differential pattern of recovery,
    rehabilitation professionals must provide two
    types of intervention.

19
Treatment Guidelines for TBI
  • The first type of intervention facilitates
    restoration of basic cognitive and communication
    processes.
  • The second type facilitates mastery,
    implementation, and generalization of
    compensatory and accommodation strategies.
  • Cognitive-communicative rehabilitation (CCR)
    encompasses the assessment and treatment of
    underlying cognitive processes as they interact
    and are manifest in communication behavior at all
    levels of language at both levels of recovery.

20
History of Cognitive-Communicative Rehabilitation
  • In the early period of program development for
    survivors of severe TBI, cognitive rehabilitation
    was understood by many practitioners as an
    enterprise that involved
  • Hierarchical organization of cognitive processes
    and sub processes
  • Creation of cognitive exercises that targeted
    specific aspects of cognition in a hierarchical
    manner and
  • Delivery of cognitive exercises outside of the
    context of functional application (e.g.,
    cognitive retraining software).

21
Process-Specific Approach to Intervention
  • The early developments in TBI rehabilitation were
    remarkably similar in theory and practice to
    unsuccessful 19th century attempts to cure mental
    retardation with hierarchically organized
    cognitive exercises.
  • In the mid-20th century learning disabilities
    were addressed with similar decontextualized
    cognitive exercises.
  • Out of these orientations grew the
    process-specific approach to intervention.

22
Process-Specific Approach to Intervention
  • This hierarchical, process-specific approach to
    intervention directly targets cognitive processes
    that are judged to interfere with successful
    communication.
  • Several published workbooks have been developed
    for use with a process-specific approach to
    target high-level cognitive skills.

23
Functional Approach to Intervention
  • In the last decade, a functional approach to
    intervention has begun to emerge that recognizes
    the importance of improving cognitive processing
    within the context of meaningful academic,
    vocational, social and other daily activities.
  • The functional approach emphasizes the concept of
    positive, supported, everyday routines of action
    and interaction with the goal of helping people
    with TBI acquire flexible and situationally
    successful routines of everyday life and apply
    appropriate scripts to guide successful thinking,
    remembering, problem solving, decision making,
    talking, and acting in social context.

24
Initial Stage of Recovery
  • As a person emerges from a coma or state of
    minimal consciousness and progresses through the
    first three Rancho Levels, pervasive medical and
    cognitive problems mask language functioning.
  • Systematic assessment of cognitive-communicative
    deficits is not possible at this time.
  • Instead, small changes in responsiveness and
    awareness of people may be observed or measured
    with the Rappaport Coma/Near Coma Scale
    (Rappaport, Dougherty, Kelting, 1992).

25
Initial Stage of Recovery
  • The Rappaport Coma/Near Coma Scale utilizes up to
    10 sensory stimuli and monitors for spontaneous
    vocalizations.
  • A professional determines a score that
    corresponds to one of five levels describing the
    severity of a persons deficits in sensory,
    perceptual, and primitive responses.
  • During this period of recovery, sensory
    stimulation is the usual course of treatment.
  • Sensory stimulation is a program aimed at
    increasing the arousal, awareness, and
    responsiveness of slow-to-recover individuals.

26
Sensory Stimulation
  • Multi-sensory stimulation occurs through several
    modalities (e.g., visual, auditory, tactile,
    gustatory, olfactory, and kinesthetic).
  • Typically, several therapeutic areas participate
    in sensory stimulation programs, and family
    members/ friends should also play a role.
  • Unfortunately, little research has been done to
    document the effectiveness of sensory stimulation
    programs.
  • The research that does exist is open to
    criticism.

27
Sensory Stimulation
  • Small sample sizes, variations across
    participants in time between injury and
    intervention, lack of control groups, selection
    biases, and methodological problems, especially
    differentiating treatment effects from
    spontaneous recovery have been criticized.
  • However, a number of researchers have documented
    positive outcomes associated with sensory
    stimulation several months post-treatment.
  • These positive outcomes include

28
Sensory Stimulation
  • increased eye opening and body movements
  • changes in pulse rate and heart rate and
  • changes in EEG readings (Hall et al., 1992 Jones
    et al., 1994 Kater, 1989 Pfurtschuller, Schwarz
    List, 1986 Wilson, Powell, et al., 1991
    Wilson, Borck Powell, Thwaites, Elliot, 1996).

29
Posttraumatic Amnesia (PTA)
  • When survivors of TBI progress from vegetative
    states to minimally responsive states, and again
    when they progress from being minimally
    responsive to displaying characteristics of PTA,
    substantial changes occur in treatment
    participation and orientation.
  • During early stages of recovery, rehab
    professionals impose sensory stimulation on the
    survivor, who has a passive role.
  • However, once a survivor begins responding to
    environmental stimuli, participation in treatment
    changes from passive to active.

30
Posttraumatic Amnesia (PTA)
  • At this stage of rehabilitation, minimally
    responsive survivors should be presented with
    tasks that allow choice making via switch
    activation or natural communication (e.g., eye
    blink hand squeeze) to indicate a preference for
    one activity or item over another.
  • The goal is to allow the survivor as much control
    over events as possible, to encourage
    communicative interaction with others, and to
    facilitate active participation in therapy.

31
Posttraumatic Amnesia (PTA)
  • Once the survivor gains skills and consistency
    with choice-making, other kinds of cognitive
    intervention is possible.
  • Cognitive treatment during PTA primarily focuses
    on improving attention, orientation, and memory.
  • Professionals should expect survivors to vary
    considerably in their attending behavior based on
    a level of fatigue, changes in medication, and
    overall emotional and cognitive status.

32
Attention
  • Paying attention to environmental events and
    stimuli is a fundamental underlying process of
    learning and memory.
  • Three kinds of attention--sustained attention,
    focused attention, and divided attention--can be
    negatively affected by TBI.
  • Sustained attention refers to the act of
    maintaining focus on a given task for a
    protracted period of time.
  • Sustained attention tasks for a survivor of TBI
    might involve looking at family pictures,
    listening to music, or answering biographical
    questions.

33
Attention
  • Focused attention involves attending to one task
    despite the presence of distracting stimuli in
    the immediate environment.
  • The same kinds of activities utilized with
    sustained attention can be performed but in
    increasingly more complex and distracting
    environments.
  • Divided attention requires a shift between two or
    more activities occurring simultaneously.

34
Attention
  • When working on divided attention, a therapist
    might request a that a survivor of TBI
    alternately read sentences on one piece of paper
    and write key words on another.
  • As attention improves, additional environmental
    distractors can be added so that therapy
    situations becomes less sterile and more like
    vocational and academic settings.
  • However, inconsistent attention is a hallmark of
    TBI, especially when a survivor is experiencing
    agitation.

35
Orientation
  • As people progress through PTA, they become
    increasingly aware of their environment and those
    around them.
  • Appropriate environmental cues can be utilized by
    family members and staff to help the survivor.
  • These include calendars, signs, stating the
    facility name and location, labels providing the
    names of specific rooms within the facility,
    written schedules of daily activities, maps of
    the facility, directional cues for navigating
    from one place to another, and simple memory logs
    of daily events.

36
Memory
  • The predominant memory impairments associated
    with PTA are retrograde and anterograde amnesia.
  • Retrograde amnesia refers to memory loss
    extending backward in time from the moment of
    injury.
  • For many survivors, the time period of retrograde
    amnesia is initially quite large, spanning
    several weeks, months, or even years.
  • With recovery, this time period often decreases
    to a few days or hours.

37
Memory
  • Anterograde amnesia refers to memory loss of
    events occurring after the time of trauma.
  • This includes the period of the coma, vegetative
    state, and minimal responsiveness.
  • The end of PTA typically coincides with the end
    of anterograde amnesia, although some survivors
    who have specific and severe deficits in forming
    new memories may experience persistent
    anterograde amnesia despite the resolution of PTA.

38
Memory
  • Formal treatment of retrograde amnesia occurs
    primarily during the period of PTA and involves
    exposing the survivor to artifacts from or
    descriptions of major life events in hopes of
    stimulating recall.
  • This can be done through review of photo albums,
    and mementos supplied by the family or through
    construction of an autobiographical notebook
    featuring a chronology of major life events
    (e.g., birth, graduation from high school, first
    job, marriage).

39
Memory
  • Treatment for anterograde amnesia begins during
    PTA but may extend into later stages of recovery
    based on the particular constellation of memory
    problems displayed by an individual survivor.
  • Initial treatment strategies are similar to those
    used to facilitate recovery of orientation--provis
    ion of verbal prompts and environmental cues.
  • One of the most frequently used techniques is to
    record daily events in a memory log or journal.

40
Memory
  • Initially, family members and rehabilitation
    staff record journal information.
  • Later as survivors regain written language
    skills, they can assume responsibility for
    writing brief synopses of events and activities
    as they occur throughout the day.

41
Secondary Stage of Recovery
  • In addition to orientation, attention, and memory
    challenges, problem solving, executive
    functioning, critical thinking, and psychosocial
    processes can be impaired.
  • A decrease in any single aspect of cognition is
    enough to create a negative effect on
    communicative competence and survivors of TBI
    typically experience multiple cognitive
    disruptions simultaneously.

42
Cognitive-Communicative Challenges
  • The numerous possible variations and combinations
    of cognitive deficits following TBI complicate
    the process of identifying and describing the
    factors that contribute to cognitive-communicative
    impairments.
  • The extent of cognitive impairment tends to
    fluctuate on a daily (sometimes hourly) basis,
    depending on changes in the individual or the
    environment.
  • Moreover, cognitive-communicative impairments
    affect overall communicative competence.

43
Cognitive-Communicative Challenges
  • Typically, survivors of TBI with these types of
    impairments have intact grammar and vocabulary
    knowledge, but they cannot participate
    efficiently and effectively in communicative
    exchanges.
  • In other words, they talk better than they
    communicate.
  • A large number of behaviors associated with
    cognitive-communicative impairments fall under
    the broad category of pragmatics.

44
Cognitive-Communicative Challenges
  • However, the specific constellation of behaviors
    associated with an individual survivor's
    cognitive- communicative impairment depends on
    his/her particular set of cognitive strengths and
    challenges.
  • Many of the symptoms of cognitive-communication
    impairments are readily apparent in the discourse
    of people with TBI.
  • Characteristics of cognitive-communicative
    impairments include

45
Cognitive-Communicative Challenges
  • Verbal disfluency
  • Lack of cohesion
  • Lack of saliency
  • Revision
  • Tangential speech
  • Topic shading
  • Lability
  • Word finding
  • Poor presupposition and
  • Irrelevant information.

46
Cognitive-Communicative Challenges
  • In particular, discourse is frequently rambling
    with inclusion of many irrelevant details.
  • Syntactic and morphological structures are fairly
    intact.

47
Cognitive-Communicative Rehabilitation
  • Several considerations guide the development of
    appropriate cognitive-communication treatment
    plans for survivors.
  • First and foremost, program plans must be
    individualized.
  • The clinician must determine how underlying
    impairments in cognition and communication (e.g.,
    deficits in memory, problem solving, attention,
    and reasoning) contribute to current disabilities
    (e.g., the inability to work, attend school,
    participate in community and leisure activities).

48
Cognitive-Communicative Rehabilitation
  • A second consideration is the need for
    multidisciplinary input when developing a plan of
    treatment.
  • With input of family members and survivors, the
    team of professionals and family identify current
    disabilities as well as activities that were
    important prior to injury and will continue to be
    important post-injury.
  • Once important activities are targeted, task
    analysis should be undertaken to identifying
    component parts of these activities to determine
    where in the activity support is needed and what
    kind of support.

49
Cognitive-Communicative Rehabilitation
  • When targeting impairments and disabilities,
    clinicians should use personally relevant
    materials and implement activities in settings
    consistent with preinjury lifestyles.
  • Multiple survivors may have apparently similar
    deficits in a particular area of functioning, but
    because of individuals differences prior to
    injury, the effect on each persons life will be
    unique.
  • Personally relevant materials provide a means of
    increasing the functionality of treatment and
    facilitate awareness of how deficits negatively
    affect daily life.

50
Cognitive-Communicative Rehabilitation
  • Positive routines and scripts should be
    structured.
  • Routines and scripts--organized internal (mental)
    representations of events, with their people,
    places, associated objects, associated language,
    and their organization--occur in the course of
    everyday social, familial, vocational,
    recreational, and educational life, and involve
    everyday communication partners, including family
    members, friends, work supervisors, and teachers.

51
Cognitive-Communicative Rehabilitation
  • With functional intervention, clinicians learn to
    move beyond commercial therapy materials, generic
    therapy activities, and exclusively clinical
    intervention settings to capitalize on activities
    that are part of the individuals daily
    behavioral repertoire (routine) and to utilize
    everyday communication partners as collaborators
    in intervention (scripts).
  • Within an everyday, routine-based approach to
    intervention, people with disability are provided
    with the supports or scaffolds needed to be
    successful.
  • The functional everyday approach to
    rehabilitation consists of a progression of
    collaborative steps.

52
Scaffolds to Successful Collaboration
  • First, staff and everyday people (ideally
    including the TBI survivor) collaborate to
    identify what is and is not working in the
    everyday routines of life.
  • Second, the same group of collaborators
    identifies what changes in everyday routines
    (e.g., environment, behavior of others, behavior
    of survivor) are needed to transform negative,
    unsuccessful routines into positive, successful
    routines and build repertoires of positive
    behavior.

53
Scaffolds to Successful Collaboration
  • Thirdly, these same persons identify the supports
    and motivators needed for positive changes in
    everyday routines.
  • Fourthly, implement whatever supports (e.g.,
    external aids, compensatory skills) are necessary
    for intensive practice of positive routines in
    real-world contexts.
  • Finally, systematically reduced/withdraw levels
    of support and expand contexts as they become
    possible.

54
Treatment Plans Settings
  • Treatment plans include both long-term and
    short-term goals.
  • Long-term goals directly and functionally address
    a survivors usual and customary day-to-day
    living skills.
  • Short-terms goals address underlying impairments
    that negatively affect a survivors independent
    performance of activities identified in long-term
    goals.
  • Initial treatment for underlying impairments or
    cognitive subskills is usually provided in
    individual or small group settings.

55
Treatment Plans Settings
  • As a survivor masters compensatory techniques,
    treatment should more closely simulate realistic
    and natural settings to create positive change in
    the survivors activity level and participation
    in daily living.
  • Moving treatment sessions to functional
    environments, such as a survivors home,
    workplace, or place of leisure, is another way to
    promote carryover of learned compensatory and/or
    accommodation strategies.

56
Goal-Plan-Do-Review Strategy
  • One of the ways in which this functional everyday
    approach can be put into action is to first
    organize specific interventions around a general
    Goal-Plan-Do-Review routine.
  • Successful people, when faced with a decision (a)
    make choices about what they wish to accomplish
    (b) set reasonable goals for themselves (based on
    their strengths and limitations) (c) create
    intelligent plans for achieving their goals (d)
    act on the plans and (e) review their
    performancewhat worked and what did not work.

57
Goal-Plan-Do-Review Strategy
  • Identify what is and is not working for the TBI
    survivor in the everyday routines of life.
  • Using the Goal-Plan-Do-Review scaffold, the goal
    portion of the intervention focuses on what
    needs/wants to be accomplished.
  • The plan portion addresses materials/equipment
    and steps/assignments needed to accomplish the
    goal and to create daily routines.

58
Goal-Plan-Do-Review Strategy
  • The do portion is the action and interaction part
    of the scaffold implemented with identified
    supports and facilitators to achieve positive and
    supported behavior at different levels of
    recovery.
  • Finally, the review portion encourages
    self-reflection and feedback about how well the
    goal was accomplished.

59
Goal-Plan-Do-Review Practice
  • Before Toms brain injury, he was one of 12
    students, worldwide, selected to study music at a
    conservatory in Europe.
  • While he was there, he played with the big
    nameslegends. He was becoming one of THE
    guyslike Kenny G.
  • Nine months before Tom left Europe, he married
    his high school sweetheart, Sara.
  • Three months before he left Europe, he finished a
    huge CDsolos, duets with the big dogs, some of
    his own compositions, the works.

60
Goal-Plan-Do-Review Practice
  • One month before he left Europe, Tom contracted
    an illness that put him in a coma for 8 months.
  • Tom and his new bride came home to tears, not
    cheers to a critical care hospital wing, not the
    couples first home to only remnants of dreams
    through CDs and photos.
  • It has been 7 years now. Tom cant talk. He can
    hardly hold a spoon. He certainly cant play his
    sax. And Sara, she pretty much takes care of Tom
    full time.

61
Goal-Plan-Do-Review Practice
  • They both loved Italian food, gardening, cooking,
    taking pictures, and music.
  • Sometimes Tom just seems so sad. Sara seems so
    tired.

62
Cognitive-Communicative Deficits in Dementia
  • The functional deficits that individuals with
    dementia experience in communication, activities
    of daily living, and quality of life result
    directly from the cognitive impairments that
    define dementia.
  • The patterns of these impairments depends upon
    the distribution of the neuropathology associated
    with the different diseases that cause dementia.
  • Historically, clinicians have participated
    extensively in the evaluation process, but have
    been somewhat reluctant to treat this population,
    due to the degenerative nature of the disease.

63
Cognitive-Communicative Deficits in Dementia
  • Despite severe impairments in some cognitive
    areas, clinicians should recognize residual
    capacities and utilize them as the springboard
    for successful interventions for dementia
    patients.
  • Treatment of patients with dementia will require
    that clinicians focus on developing innovative
    strategies to help clients compensate for the
    their communicative difficulties
  • When working with patients with dementia, the
    following principles should be applied.

64
Principles of Intervention in Dementia
  • First, reduce demands on episodic
    (autobiographical memory encoded in a
    temporal/spatial context) and working memory
    systems.
  • Second, increase reliance on nondeclarative
    memory systems (verbal and motor procedural
    memory subsystems, reflexes, and habit memory).
  • Third, provide activities that strengthen lexical
    and conceptual associations.
  • Fourth, provide sensory cues that evoke positive
    fact memory, action, and emotion.

65
Spaced Retrieval Strategy
  • One general approach to intervention with
    individuals with dementia of the Alzheimers type
    is to capitalize on relatively preserved
    nondeclarative memory abilities.
  • The Spaced Retrieval Strategy (Bjork, 1988
    Landauer Bjork, 1978), also referred to as
    Spaced Retrieval Training (SRT Camp, 1996) is a
    treatment method that capitalizes on
    implicitunintentional or nonconscious--learning.
  • SRT is frequently used to teach new and forgotten
    information and behaviors to patients with
    dementia.

66
Spaced Retrieval Strategy
  • The Spaced Retrieval Strategy (SRS) consists of
    retrieving the information to be learned after
    increasingly longer temporal delays.
  • In SRT, a person is told a piece of information
    and then is asked to recall that information
    repeatedly and systematically over time.
  • Intervals are manipulated to facilitate
    production of a high number of correct responses
    to the stimulus question and retention of
    information over increasing longer periods of
    time.

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Spaced Retrieval Strategy
  • The temporal delays between retrieval can be
    filled by conversation, playing games, etc.
  • SRS has been demonstrated to facilitate
    prospective memory, the ability to remember to
    carry out specified actions at future target
    times.
  • The SRS memory method is effortless, because
    the learning seems to occur without full
    cognitive effort on the part of the patient.

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Spaced Retrieval Strategy
  • For example, lets say you want to teach a person
    with AD to use an external memory aid, such as a
    calendar.
  • The strategy you want the patient with AD to
    remember is Look at the calendar.
  • Present the calendar to the patient and say, How
    are you going to remember what to do each day?
  • You want the patient to learn to say Look at my
    calendar.
  • With the calendar, orient the patient by saying
    What day is today? What activities are scheduled
    for today? What time is lunch today?

69
Spaced Retrieval Strategy
  • After completing orientation to the calendar, the
    patient and clinician would then ask, How do you
    know what you are you going to do today?
  • If the response is correct, the clinician would
    go onto another therapy task.
  • If the response was incorrect, the clinician
    would provide the correct answer and then
    immediately repeat the prompt question again.
  • If the response is correct, the clinician would
    go onto another therapy task and at a natural
    break in the session, the clinician would again
    ask the prompt question.

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Spaced Retrieval Strategy
  • When the patient can recall the strategy after a
    one-week interval, SRT is terminated.
  • SRT is useful for teaching face-name
    associations, autobiographical information, and
    other compensatory techniques to enhance
    communication.

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Errorless Learning
  • Another treatment approach that capitalizes on
    spared memory systems that may be beneficial for
    promoting new learning by individuals with AD is
    errorless learning.
  • Errorless learning involves minimization of the
    the number of errors that are allowed to occur
    during learning trials.
  • Individuals with episodic memory impairment have
    difficulty eliminating error made during learning
    trials because they cannot explicitly recall the
    learning experience.

72
Errorless Learning
  • If one use a trial and error approach, these
    individuals will continue to make the same errors
    on subsequent trials rather than learning from
    their errors and making corrections.
  • Bourgeois (1990 1992) has demonstrated improved
    functioning in dementia patients by capitalizing
    on spared recognition memory and decreasing
    demands on impaired episodic and working memory
    systems.
  • Using memory wallets of photographs of persons
    and places of interest, caregivers can be trained
    to use these wallets in conversation with their
    loved one.

73
Errorless Learning
  • Bourgeois has found that patients make
    significantly more statements of fact and few
    ambiguous utterances when the wallets are
    present.
  • When such as stimulus remains visible in a
    conversation, it alleviates the demands that
    conversation typically places on working memory.
  • Additionally, the photographs stimulate
    recognition of episodes and people in the
    patients lives, reducing reliance on free recall
    that usually occurs during conversation about
    remote and recent events.

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Sensory Stimulation Strategy
  • Another successful treatment technique evoking
    positive face memory, action, and emotion is the
    use of sensory stimulation.
  • Stuffed animals or decorations/knick-knacks found
    in a patients room have been observed to improve
    levels of alertness, positive emotion (smiling
    and nodding), and decreased agitation during
    therapeutic attempts to improve conversation and
    social interaction.

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Montessori-Based Intervention
  • A program based on several of the techniques just
    mentioned as well as the life experiences of AD
    patients is the Montessori-based intervention
    developed and described by Camp et al. (1997).
  • Montessori programming promotes learning through
    procedural memory processes, and utilizes
    concrete everyday stimuli to facilitate action
    and memory, while reducing demands on episodic
    and working memory by using repeated structured
    tasks and materials.

76
Montessori-Based Intervention
  • Intergenerational Montessori programming between
    individuals with dementia and children has been
    positive.
  • Children are matched with an adult who is a bit
    more cognitively advanced than the child to allow
    the adult to act as the mentor or teacher with
    the child during a Montessori activity, such as
    matching, sorting, or reading aloud.
  • Camp, C. J., Judge, K. S., Bye, C. A., Fox, K.
    M., Bowden, J., Bell, M., Valencic, K.,
    Mattern, J.M. (1997). An intergenerational
    program for persons with dementia using
    Montessori methods. The Gerontologist, 37 (5),
    688-692.

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Volunteers in Partnership
  • Another type of treatment program that utilizes
    collaboration between volunteers and patients
    with AD is the Volunteers in Partnership (VIP
    Arkin, 1995) program.
  • Mild-to-moderate patients with AD are paired with
    university students who assist them in performing
    weekly volunteer services and who provide memory
    and language stimulation.
  • Volunteer activities are tailored to each
    patients preferences, and may include helping at
    day-care centers, working at animal shelters, and
    assisting other residents in the nursing home.

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Volunteers in Partnership
  • Memory and language tasks are designed by the
    clinician and student are trained to use
    audiotaped quizzes to teach memory for factual
    information and to stimulate language through
    association, picture description, solicitation by
    the student of opinions or advice of how to solve
    real-life problems.
  • VIP also has the added benefit of providing
    respite for caregivers.

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Caregiver Functional Communication Training
  • For caregivers of AD patients, Ripich (1994) has
    developed a functional communication training
    program called FOCUSED.
  • This seven-step program uses each letter in the
    word FOCUSED to refer to a strategy for improving
    communication.
  • Ffunctional and face to face
  • Oorient to topic
  • Cconcrete topics
  • Uunstick any communication blocks

80
Caregiver Functional Communication Training
  • Sstructure with yes/no and choice questions
  • Eencourage interaction exchange conversation
  • Ddirect, short, simple sentences.
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