Bridging the Gap: SLP Approaches for Persons With Early Stage Dementia Philosophically different pathways and opinions exist regarding speech-language pathology services for persons living with dementia. Many believe we should be involved in leveling or staging all dementia patients and that our services are medically necessary for most diagnosed with dementia. Others deem that speech-language pathology services are not beneficial for ... Article
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Article  |   April 20, 2016
Bridging the Gap: SLP Approaches for Persons With Early Stage Dementia
Author Affiliations & Notes
  • Michelle Tristani
    Speech Pathology Clinical Specialist, Kindred Healthcare
    Speech Pathologist, St. Elizabeth's Medical Center
    Alzheimer's Association Helpline Counselor, Boston, MA
  • Disclosures: Financial: Michelle Tristani has no relevant financial interests to disclose.
    Disclosures: Financial: Michelle Tristani has no relevant financial interests to disclose.×
  • Nonfinancial: Michelle Tristani has no relevant nonfinancial interests to disclose.
    Nonfinancial: Michelle Tristani has no relevant nonfinancial interests to disclose.×
Article Information
Special Populations / Older Adults & Aging / Attention, Memory & Executive Functions / Part 1
Article   |   April 20, 2016
Bridging the Gap: SLP Approaches for Persons With Early Stage Dementia
Perspectives of the ASHA Special Interest Groups, April 2016, Vol. 1, 4-11. doi:10.1044/persp1.SIG15.4
History: Received September 4, 2015 , Revised October 14, 2015 , Accepted November 20, 2015
Perspectives of the ASHA Special Interest Groups, April 2016, Vol. 1, 4-11. doi:10.1044/persp1.SIG15.4
History: Received September 4, 2015; Revised October 14, 2015; Accepted November 20, 2015

Philosophically different pathways and opinions exist regarding speech-language pathology services for persons living with dementia. Many believe we should be involved in leveling or staging all dementia patients and that our services are medically necessary for most diagnosed with dementia. Others deem that speech-language pathology services are not beneficial for this population and that we should not be involved because of the progressive nature of the disease and its resulting obstruction to learning new information. Achieving a clinically appropriate balance is needed if we are to bridge the gap between both approaches. Realization of a middle ground calls for agreement regarding criteria for cognitive evaluation, components of skilled cognitive intervention, and a framework for significant progress. Once consensus is achieved for these preliminary elements, speech-language pathologists will be in a better position to: develop functional, reasonable, and necessary cognitive treatment procedures; formulate objective, measurable, and individualized goals; and prioritize safety, communication, and quality of life within cognitive management pathways for all stages of dementia. The early stage dementia diagnosis presents unique challenges and opportunities for speech-language pathologists. We begin here in reducing the gap in our cognitive approaches for the dementia population.

Lisa Genova's novel, “Still Alice”, describes the initial response to receipt of Alzheimer's diagnosis as follows: “taking Aricept and Namenda felt like aiming a couple of leaky squirt guns into the face of a blazing fire.” (Genova, 2009) Although there are many anti-depressants available, it is difficult to believe that any single one can improve the outlook of persons with early stage dementia who often possess awareness of losing their sense of self. The overwhelming nature of the diagnosis and its ensuing devastation on all aspects of life may halt a person's momentum. In the NY Times article, “The Last Day of Her Life,” (Marantz Henig, 2015) Sandy Bem is supported by family and friends when she vows to end her life before Alzheimer's robs it from her. The article illustrates a heart wrenching wish that many with early stage dementia face. For some it is a fleeting thought or impulse. For others, it is a well thought out decision and multistep plan as the person with early stage dementia maximizes use of some preserved executive functions. In either case, persons diagnosed begin the fight against time and its negative effects of tau and beta amyloid building up throughout the brain.
In order to make a positive impact and overcome inertia, after initial diagnosis, the speech-language pathologist (SLP) must first obtain a detailed, heightened awareness of the daily challenges the person with early stage dementia is battling against. The initial loss of independence can be overwhelming. Struggles in the early stage may include, but are not limited to, denial, depression, short-term memory loss, paranoia, repetitive question asking, and changes in sleep patterns, smell, and taste (Raia & Koenig-Coste, 1996). Persons with early stage dementia also experience difficulty with visual perception, word retrieval, semantic memory (Joubert et al., 2010), wayfinding, driving, executive functions, and financial and medication management (Brandt et al., 2009).
Mild Cognitive Impairment (MCI) Versus Early Stage Dementia
Mild cognitive impairment (MCI) and early stage dementia are two separate and distinct diagnoses and levels of cognitive ability. Persons with MCI are at increased risk of developing dementia, yet not everyone with MCI progresses to dementia. New learning with trial-and-error problem-solving and repetition remain a strength for those with MCI (Dementia Care Specialists, 2014). Whereas the individual with MCI is able to live independently, work with some modifications, perform child care, drive, and learn new information, those with early stage dementia are not only challenged by the latter tasks, but also require cognitive support for activities that are new or more complex and exhibit poor judgment and compromised safety awareness. Persons with early stage dementia often require minimal cognitive assistance for all activities of daily living (ADL) except self-feeding, which remains at an independent or supervised level until the later stages of the disease. There is a range of abilities within early stage dementia. At the low level early stage, individuals follow routines and require supervision and set up, reminders, and assistance with complex, new activities or equipment. At the high level early stage, persons are independent in basic ADLs, utilizing lists, notes, calendars, and other visual organization aids; they benefit from practice when approaching complex or new activities. Persons with early stage dementia, have some degree of preserved new learning and simple problem solving (Dementia Care Specialists, 2014).
Evaluation of Cognitive Skills—Early Stage Dementia
There are many standardized cognitive assessments that appeal to the SLP's hectic schedule. Several cognitive test titles include the terms “quick,” “brief,” or “stat.” Although an efficient assessment is beneficial, the SLP must ensure the test measures selected are individualized and comprehensive enough to develop a thorough plan of care; including treatment intensity, frequency and duration, short- and long-term goals, cognitive treatment procedures, and caregiver education and training. In order for caregiver training to be relevant and beneficial, it must include trialed, effective, and customized cognitive strategies, approaches, and environmental modifications.
The Mini-Mental Status Exam, Montreal Cognitive Assessment and St. Louis University Mental Status Exam, to name a few, are inherently “starter” tests that direct the SLP to cognitive strengths and challenges that warrant more in-depth testing. Comprehensive assessments generate a treatment plan with a clear path and direction and therefore allow us to more easily measure progress and document outcomes (Table 1). Paramount in the evaluation of persons with early stage dementia is the assessment of new learning capability. In order to fully assess new learning skills, we must focus on determining working memory abilities. Working memory is defined by our ability to hold information and subsequently manipulate it. Once new learning ability is determined, we are then able to develop a functional treatment plan. A functional plan of treatment considers the person with early stage dementia and their daily roles and responsibilities (i.e. what a typical day looks like) and guides the SLP away from workbook activities (which are often times non-functional) as the primary treatment activity.
Table 1. Early Stage Dementia Cognitive Assessment Measures
Early Stage Dementia Cognitive Assessment Measures×
Brief Cognitive Assessment Tool A 20-minute assessment with 50-point total score
Subtests Include: orientation, immediate verbal recall, visual recognition/naming, attention, abstraction, language, executive, visuospatial, delayed verbal recall, immediate story recall, delayed visual memory, delayed story recall, story recognition
Repeatable Battery for the Assessment of Neuropsychological Status Update (RBANS® Update) A valuable initial or repeat test measure utilized as a stand-alone comprehensive assessment for the detection and characterization of dementia in the elderly. Subtests include: immediate memory—list learning and story memory, visuospatial/constructional—figure copy and line orientation, language—picture naming and semantic fluency, attention—digit span and coding, delayed memory—list recall, list recognition, story memory, and figure recall (Randolph, 2012)
Arizona Battery for Communication/Cognitive Disorders (ABCD) Standardized test battery for the comprehensive assessment of dementia patients. Includes 14 subtests that evaluate linguistic expression, linguistic comprehension, verbal episodic memory, visuospatial construction, and mental status (Bayles & Tomoeda, 1993) 
Cognistat Assesses neurocognitive functioning for many areas: level of consciousness, orientation, attention span, language, constructional ability, memory, calculation skills, reasoning/ judgment
Cognitive Linguistic Quick Test (CLQT) Assesses strengths and weaknesses in five cognitive domains: attention, memory, executive functions, language, and visual-spatial skills
Clock Drawing Executive Test (CLOX) Quick overview of visual neglect, planning, problem-solving, overall cognitive function. Also comprehension/attention to written vs. verbal directives. Measures executive control function (ECF). ECFs are cognitive processes that coordinate simple ideas and actions into complex goal directed behaviors. Examples include goal selection, motor planning sequencing, selective attention, and the self-monitoring of one's current action plan. All are required for successful clock-drawing.
Self Administered Gerocognitive Examination (SAGE) SAGE is a brief self-administered cognitive screening instrument to identify Mild Cognitive Impairment (MCI) and early dementia. Average time to complete the test is 10 to 15 minutes.
Assessment of Language-Related Functional Activities (ALFA) Organized into 10 subtests (understanding medicine labels, solving daily math problems, writing checks, etc.)
Burns Brief Inventory of Communication and Cognition Three Inventories—right hemisphere, left hemisphere, and complex neuropathology
Executive Function Performance Test (EFPT) Assesses cognitive integration and functioning in an environmental context. Unlike other tests of function, the EFPT does not examine what individuals cannot do. Rather, it identifies what they can do and how much assistance is needed to carry out a task
Test of Everyday Attention Measure selective, sustained, and alternating attention
Trail Making Test Test of visual attention and task switching/alternating
Personal History Interview Informal checklist of past and current occupational and leisure topics of interest that serve to motivate
Addenbrooke's Cognitive Exam (ACE-III) Brief, yet comprehensive, cognitive test with a maximum score of 100
Environment & Communication Assessment Toolkit for Dementia Care Comprehensive environmental analysis of visual and auditory stimuli in personal and public spaces
3 Words / 3 Shapes Test Subtest of auditory and visual memory (Mesulam, 1985)
Hidden Objects Test (informal) Informal, functional subtest of auditory and visual memory
Auditory and visual cancellation tasks To evaluate visual and auditory attention, concentration, organization, task approach
Table 1. Early Stage Dementia Cognitive Assessment Measures
Early Stage Dementia Cognitive Assessment Measures×
Brief Cognitive Assessment Tool A 20-minute assessment with 50-point total score
Subtests Include: orientation, immediate verbal recall, visual recognition/naming, attention, abstraction, language, executive, visuospatial, delayed verbal recall, immediate story recall, delayed visual memory, delayed story recall, story recognition
Repeatable Battery for the Assessment of Neuropsychological Status Update (RBANS® Update) A valuable initial or repeat test measure utilized as a stand-alone comprehensive assessment for the detection and characterization of dementia in the elderly. Subtests include: immediate memory—list learning and story memory, visuospatial/constructional—figure copy and line orientation, language—picture naming and semantic fluency, attention—digit span and coding, delayed memory—list recall, list recognition, story memory, and figure recall (Randolph, 2012)
Arizona Battery for Communication/Cognitive Disorders (ABCD) Standardized test battery for the comprehensive assessment of dementia patients. Includes 14 subtests that evaluate linguistic expression, linguistic comprehension, verbal episodic memory, visuospatial construction, and mental status (Bayles & Tomoeda, 1993) 
Cognistat Assesses neurocognitive functioning for many areas: level of consciousness, orientation, attention span, language, constructional ability, memory, calculation skills, reasoning/ judgment
Cognitive Linguistic Quick Test (CLQT) Assesses strengths and weaknesses in five cognitive domains: attention, memory, executive functions, language, and visual-spatial skills
Clock Drawing Executive Test (CLOX) Quick overview of visual neglect, planning, problem-solving, overall cognitive function. Also comprehension/attention to written vs. verbal directives. Measures executive control function (ECF). ECFs are cognitive processes that coordinate simple ideas and actions into complex goal directed behaviors. Examples include goal selection, motor planning sequencing, selective attention, and the self-monitoring of one's current action plan. All are required for successful clock-drawing.
Self Administered Gerocognitive Examination (SAGE) SAGE is a brief self-administered cognitive screening instrument to identify Mild Cognitive Impairment (MCI) and early dementia. Average time to complete the test is 10 to 15 minutes.
Assessment of Language-Related Functional Activities (ALFA) Organized into 10 subtests (understanding medicine labels, solving daily math problems, writing checks, etc.)
Burns Brief Inventory of Communication and Cognition Three Inventories—right hemisphere, left hemisphere, and complex neuropathology
Executive Function Performance Test (EFPT) Assesses cognitive integration and functioning in an environmental context. Unlike other tests of function, the EFPT does not examine what individuals cannot do. Rather, it identifies what they can do and how much assistance is needed to carry out a task
Test of Everyday Attention Measure selective, sustained, and alternating attention
Trail Making Test Test of visual attention and task switching/alternating
Personal History Interview Informal checklist of past and current occupational and leisure topics of interest that serve to motivate
Addenbrooke's Cognitive Exam (ACE-III) Brief, yet comprehensive, cognitive test with a maximum score of 100
Environment & Communication Assessment Toolkit for Dementia Care Comprehensive environmental analysis of visual and auditory stimuli in personal and public spaces
3 Words / 3 Shapes Test Subtest of auditory and visual memory (Mesulam, 1985)
Hidden Objects Test (informal) Informal, functional subtest of auditory and visual memory
Auditory and visual cancellation tasks To evaluate visual and auditory attention, concentration, organization, task approach
×
Working memory is a representation of new learning capacity. It details our ability to gain and retain new information, retrieve memories, “shift gears,” and function independently. To assess working memory and new learning ability, it is valuable to utilize tools and subtests that evaluate immediate and delayed recall as well as recognition (selection of targeted stimuli from a choice of correct and incorrect information). The SLP must interpret the results garnered from selected subtests related to the cognitive hierarchy (Figure 1). A minimum degree of recall or recognition is required to learn a new task or retain visual or auditory information. Immediate and delayed story re-telling subtests are sensitive to identification of early stage dementia due to impairment in episodic memory (Mansbach, Mace, & Clark, 2014). Furthermore, reasoning and visual processing speed are key skills to incorporate into our evaluations, as both are indicators for success in completion of instrumental activities of daily living (IADL; Willis et al., 2006).
Figure 1.

The Cognitive Skills Hierarchy

 The Cognitive Skills Hierarchy
Figure 1.

The Cognitive Skills Hierarchy

×
Another important memory type in the evaluation of persons with early stage dementia includes procedural memory, which is memory for motor routines, basic and automatic activities, and habits; memory for how a task is performed. Some examples include playing the piano, tying a shoe, starting a car, riding a bike, and writing with a pen. A person with preserved procedural memory may be able to defeat you at a familiar card or board game, but may be unable to tell you the name of the game or how to play.
Skilled Cognitive-Communication Treatment - Early Stage Dementia
In order to connect our two polarized perspectives, SLPs must agree on a range of evaluation and treatment procedures that are skilled. Furthermore, it would also be advantageous to determine a generally agreed upon process to assign frequency and duration of treatment once medically necessary outcomes are achieved (Table 2).
Table 2. Frequency of Treatment Clinical Decision Making Guide
Frequency of Treatment Clinical Decision Making Guide×
3x Lean Toward 3x/week ← Clinical Factors → Lean Toward 5x/week 5x
← Low - Medical Complexity – Acuity Level – High →
← Simple - Clinical Complexity – Multiple Treatment Procedures - Complex →
← Long Term Care - Discharge Setting – Home – ALF →
← Long - Estimated Facility Length of Stay – Short →
← Low - Patient Motivation and Participation – High →
← Low - Safety Awareness and Strategies as a Priority in Treatment – High →
← Appropriate - Spaced Retrieval / Higher Level Memory Interventions – Not Appropriate →
← Minimal - Rate and Amount of Weekly Progress – Significant →
Table 2. Frequency of Treatment Clinical Decision Making Guide
Frequency of Treatment Clinical Decision Making Guide×
3x Lean Toward 3x/week ← Clinical Factors → Lean Toward 5x/week 5x
← Low - Medical Complexity – Acuity Level – High →
← Simple - Clinical Complexity – Multiple Treatment Procedures - Complex →
← Long Term Care - Discharge Setting – Home – ALF →
← Long - Estimated Facility Length of Stay – Short →
← Low - Patient Motivation and Participation – High →
← Low - Safety Awareness and Strategies as a Priority in Treatment – High →
← Appropriate - Spaced Retrieval / Higher Level Memory Interventions – Not Appropriate →
← Minimal - Rate and Amount of Weekly Progress – Significant →
×
The widespread question of “Can dementia patients learn?” remains a hot debate among cognitive clinicians—SLPs, Occupational Therapists, Neuropsychologists, and Physicians alike. As long as our assessment of new learning capacity is comprehensive and accurate, we will be able to develop a clinically appropriate and effective treatment plan. Because early stage dementia appreciates some new learning ability, the door is still open for a multitude of traditional as well as advanced cognitive treatment procedures and compensatory strategies.
Instrumental activities of daily living (IADLs) that may be incorporated into treatment if they are part of a person's typical daily schedule or interests include: medication and money management, shopping, scheduling appointments, way-finding, newspapers, magazines, calendars, phone, tablet, television, radio, remote control, alarms, and maps. It is advantageous to analyze each task by identifying which primary cognitive skills (Figure 1) are warranted for effective activity completion. For example, way-finding tasks require visual memory, visual attention, concentration, problem solving, and spatial processing abilities. It is also helpful to consider familiarity with the environment, prominence of landmarks, and layout of the environment.
The spaced retrieval technique is clinically appropriate for the early dementia population due to preserved new learning at this juncture. Spaced retrieval can be used to attain treatment goals related to: compensatory strategies for mobility, ADLs, and swallowing; safety precautions; adaptive equipment and ambulation devices; call bell system; and environmental orientation aids. The technique can reduce behaviors such as repetitive question asking that in turn may increase independence and reduce anxiety. Additional treatment techniques appropriate to trial with early stage dementia include: visual imagery, mneumonics (Hampstead, Stringer, Stilla, Giddens, & Sathian, 2012), acronymns, associations, rehearsal, repetition, redirection, and reality orientation (Clare & Woods, 1996). The SLP can assist with additional unique considerations related to early stage dementia including driving, holiday routines, and employment.
Determining Skill
Although many cognitive techniques are beneficial to persons with dementia, not all of them need to be provided by a licensed, American Speech-Language-Hearing Association (ASHA)-certified SLP; not all interventions and approaches are skilled. The definition of “skilled” services according to the Centers for Medicare and Medicaid states:

A service is not considered a skilled therapy service merely because it is furnished by a therapist… Skilled therapy services may be necessary to improve a patient's current condition, to maintain the patient's current condition, or to prevent or slow further deterioration of the patient's condition… To be considered reasonable and necessary, below are a few of the conditions that must be met:

  • The services shall be considered under accepted standards of medical practice to be a specific and effective treatment for the patient's condition.

  • The services shall be of such a level of complexity and sophistication or the condition of the patient shall be such that the services required can be safely and effectively performed only by a therapist

  • The amount, frequency, and duration of the services must be reasonable under accepted standards of practice. The contractor shall consult local professionals or the state or national therapy associations in the development of any utilization guidelines. (Medicare Benefit Policy Manual, 2015, Chapter 8. Section 30.2.2)

Clinical reasoning to initiate and continue to provide skilled SLP services for persons with early stage dementia includes the components outlined in Table 3.
Table 3. Early Stage Dementia Cognitive Treatment Clinical Decision Making Guide
Early Stage Dementia Cognitive Treatment Clinical Decision Making Guide×
Points that drive the treatment program for persons with early stage dementia:
 • A valid reason for cognitive referral such as change in communication and/or cognitive status
 • Completion of a comprehensive evaluation with determination of the stage of dementia and the individual's new learning capacity
 • Identifying safety awareness skills particularly in activities such as cooking, driving, medications, money management
 • Development of a daily schedule, typical day to day roles, responsibilities related to communication and cognitive abilities
 • Selection of relevant treatment activities / personally influenced by interests, values and culture (this will insure a functional treatment program)
 • Determine individualized, effective communication and cognitive strategies
 • Educate and train all caregivers / family on effective strategies in order to discharge from SLP services with confidence
 • Significant or insignificant rate and amount of progress from week to week compared to short term goals
 • Consult with other rehab team members or medical staff on resolution of barriers interfering with treatment or needed follow up consultations impacting treatment
 • Identification of preserved cognitive or language based strengths (e.g. reading comprehension, clock interpretation, preference for visual cues) to determine if they are strong enough to assist in overcoming areas of challenge
 • Defining individualized quality of life
Table 3. Early Stage Dementia Cognitive Treatment Clinical Decision Making Guide
Early Stage Dementia Cognitive Treatment Clinical Decision Making Guide×
Points that drive the treatment program for persons with early stage dementia:
 • A valid reason for cognitive referral such as change in communication and/or cognitive status
 • Completion of a comprehensive evaluation with determination of the stage of dementia and the individual's new learning capacity
 • Identifying safety awareness skills particularly in activities such as cooking, driving, medications, money management
 • Development of a daily schedule, typical day to day roles, responsibilities related to communication and cognitive abilities
 • Selection of relevant treatment activities / personally influenced by interests, values and culture (this will insure a functional treatment program)
 • Determine individualized, effective communication and cognitive strategies
 • Educate and train all caregivers / family on effective strategies in order to discharge from SLP services with confidence
 • Significant or insignificant rate and amount of progress from week to week compared to short term goals
 • Consult with other rehab team members or medical staff on resolution of barriers interfering with treatment or needed follow up consultations impacting treatment
 • Identification of preserved cognitive or language based strengths (e.g. reading comprehension, clock interpretation, preference for visual cues) to determine if they are strong enough to assist in overcoming areas of challenge
 • Defining individualized quality of life
×
Significant Progress
In order to justify continued cognitive services, persons with early stage dementia must demonstrate significant progress. Defining “significant” in “significant progress” can be complicated. For the purposes of early stage dementia, “significant” often means to make a difference in/contribute to everyday life. The person with dementia needs to be able to generalize the use of strategies within ADLs and IADLs independently or with intermittent-to-minimal verbal or visual cues/assistance/aids. If progress is not realistic or evident, we must trial individualized strategies, determine their effectiveness, train caregivers, and discharge. Significant progress is one of several factors considered when determining the most effective and clinically appropriate treatment frequency as illustrated in Table 2. When using the guide, we are encouraged to take into account and address the combination of clinical areas at evaluation and at intervals of treatment that most impact treatment frequency. If progress is slower and most treatment areas have been addressed, we may consider reducing treatment frequency from 5 to 3 times per week to continue education and training as an adjunct to cognitive focus areas.
Individual Versus Basic Cognitive Strategies
Basic strategies are appropriate for all individuals and are often part of caregiver education programs and a nursing assistant competency. Individualized cognitive strategies are specialized techniques specific to a person that extend beyond basic cognitive strategies. SLPs select indicated techniques based on skilled evalulation and treatment and train caregivers as appropriate. Individualized strategies are also outlined in the discharge summary. When we train patients and caregivers using effective, individualized strategies, our services are inherently skilled.
Power + Purpose Program
The Alzheimer's Association Massachusetts/New Hampshire Chapter has developed a specialized program for individuals diagnosed with mild Alzheimer's disease known as the Power + Purpose Program (http://www.alzmass.org/pp/). The program empowers persons with mild Alzheimer's, their friends, and their family with educational programs that focus on what to expect, steps to sharing the diagnosis, stress management, and taking care of oneself. Portions of these educational programs are led by a person with mild Alzheimer's. The engagement portion of Power + Purpose capitalizes on the individual interests of persons with early stage memory loss and enables them to maintain physical, mental, and social activity involvement. Care Consultations are part of the program, wherein persons with mild Alzheimer's, their family, and their friends receive one-on-one assistance in preparing a road map to direct their questions, concerns, needs, goals, and plans. The program also has opportunities to advocate for research, programs, and funding to become a part of the fight against the disease (Alzheimer's Association, Massachusetts/New Hampshire Chapter, 2015). Referring persons with early stage dementia to their local Alzheimer's Association is a valuable first step.
Consensus Statement on Clinical Judgment in Health Care Settings
The Consensus Statement on Clinical Judgment in Healthcare Settings is the first of its kind and speaks volumes as three national organizations that guide the professions of physical and occupational therapy and speech-language pathology (American Physical Therapy Association, American Occupational Therapy Association, and ASHA, respectively) converge to clarify that the provision of ethical, skilled, and evidence-based services are the independent decision of the evaluating and treating clinician. The consensus statement, published in October 2014, further supports and advises clinicians to recognize and take action when unethical guidance is provided by employers. The statement serves to further bridge the gap between the two philosophically different approaches to speech-language pathology services in persons with dementia (Alzheimer's Association, Massachusetts/New Hampshire Chapter, 2015).
Concluding Statements
It is easy to be there for family, friends, patients, clients, and caregivers in the midst of success and ease of life. It is the true test of our personal relationships and professional and clinical excellence in difficult times and when a diagnosis of dementia hits. As we await effective medical treatment for dementia, we have the opportunity to make a positive impact on the quality of life of our patients and caregivers in the face of one of the most devastating diagnoses and life events of our time. Bridging the philosophical gap in speech-language pathology services for persons with dementia encompasses the areas of clinical reasoning reviewed. As outlined, the cognitive clinical pathway for persons with early stage dementia may include skilled speech-language pathology services, functional progress, effective individualized strategies, patient and caregiver education, and positive patient outcomes. When skilled speech-language pathology services are not indicated, we remain empowered to educate and guide caregivers to enhance communication and advocacy and promote safe, independent living for as long as possible for persons with early stage dementia.
References
Alzheimer's Association, Massachusetts/New Hampshire Chapter. (2015). Power & Purpose Program. Retrieved from http://www.alzmass.org/pp/
Alzheimer's Association, Massachusetts/New Hampshire Chapter. (2015). Power & Purpose Program. Retrieved from http://www.alzmass.org/pp/ ×
Bayles, K. A., & Tomoeda, C. K. (1993). Arizona battery for communication disorders of dementia. Austin, TX: Pro-ED.
Bayles, K. A., & Tomoeda, C. K. (1993). Arizona battery for communication disorders of dementia. Austin, TX: Pro-ED.×
Brandt, J., Aretouli, E., Neijstrom, E., Samek, J., Manning, K., Albert, M., & Bandeen-Roche, K. (2009). Selectivity of executive function deficits in mild cognitive impairment. Neuropsychology, 23, 607–618. [Article] [PubMed]
Brandt, J., Aretouli, E., Neijstrom, E., Samek, J., Manning, K., Albert, M., & Bandeen-Roche, K. (2009). Selectivity of executive function deficits in mild cognitive impairment. Neuropsychology, 23, 607–618. [Article] [PubMed]×
Centers for Medicare and Medicaid Services. (2015). Covered medical and other health services—Transmittal 220. (2015). In Medicare Benefit Policy Manual (pp. 169–178). Indpendence, MO: Author.
Centers for Medicare and Medicaid Services. (2015). Covered medical and other health services—Transmittal 220. (2015). In Medicare Benefit Policy Manual (pp. 169–178). Indpendence, MO: Author.×
Clare, L., & Woods, B. (1996). Cognitive rehabilitation and cognitive training for early-stage Alzheimer's disease and vascular dementia. Cochrane Database of Systematic Reviews Reviews, 4.
Clare, L., & Woods, B. (1996). Cognitive rehabilitation and cognitive training for early-stage Alzheimer's disease and vascular dementia. Cochrane Database of Systematic Reviews Reviews, 4.×
Dementia Care Specialists. (2014, August). Dementia capable care: Dementia therapy applications. Retrieved from http://www.crisisprevention.com/Products/Online-Dementia-Capable-Care-Dementia-Therapy-Ap
Dementia Care Specialists. (2014, August). Dementia capable care: Dementia therapy applications. Retrieved from http://www.crisisprevention.com/Products/Online-Dementia-Capable-Care-Dementia-Therapy-Ap ×
Genova, L. (2009). Still Alice: A novel. New York, NY: Pocket Books.
Genova, L. (2009). Still Alice: A novel. New York, NY: Pocket Books.×
Hampstead, B., Stringer, A., Stilla, R., Giddens, M., & Sathian, K. (2012). Mnemonic strategy training partially restores hippocampal activity in patients with mild cognitive impairment. Hippocampus, 22, 1652–1658. [Article] [PubMed]
Hampstead, B., Stringer, A., Stilla, R., Giddens, M., & Sathian, K. (2012). Mnemonic strategy training partially restores hippocampal activity in patients with mild cognitive impairment. Hippocampus, 22, 1652–1658. [Article] [PubMed]×
Joubert, S., Brambati, S., Ansado, J., Barbeau, E., Felician, O., Didic, M., … Kergoat, M. (2010). The cognitive and neural expression of semantic memory impairment in mild cognitive impairment and early Alzheimer's disease. Neuropsychologia, 48, 978–988. [Article] [PubMed]
Joubert, S., Brambati, S., Ansado, J., Barbeau, E., Felician, O., Didic, M., … Kergoat, M. (2010). The cognitive and neural expression of semantic memory impairment in mild cognitive impairment and early Alzheimer's disease. Neuropsychologia, 48, 978–988. [Article] [PubMed]×
Mansbach, W. E., Mace, R. A., & Clark, K. M. (2014). Story recall and word list: Differential and combined utilities in predicting cognitive diagnosis. Journal of Clinical and Experimental Neuropsychology, 36, 569–576. [Article] [PubMed]
Mansbach, W. E., Mace, R. A., & Clark, K. M. (2014). Story recall and word list: Differential and combined utilities in predicting cognitive diagnosis. Journal of Clinical and Experimental Neuropsychology, 36, 569–576. [Article] [PubMed]×
Marantz Henig, R. (2015, May 17 ). The last day of her life. The New York Times Magazine.
Marantz Henig, R. (2015, May 17 ). The last day of her life. The New York Times Magazine.×
Mesulam, M. M. (1985). Principles of behavioral neurology. Philadelphia, PA: F.A. Davis.
Mesulam, M. M. (1985). Principles of behavioral neurology. Philadelphia, PA: F.A. Davis.×
Raia, P., & Koenig-Coste, J. (1996). Habilitation therapy: Realigning the planets. Newsletter of the Eastern Massachusetts Alzheimer's Association, 14(1), 12–14.
Raia, P., & Koenig-Coste, J. (1996). Habilitation therapy: Realigning the planets. Newsletter of the Eastern Massachusetts Alzheimer's Association, 14(1), 12–14.×
Randolph, C. (2012). Repeatable battery for the assessment of neuropsychological status. PsycTESTS Dataset. Retrieved from http://www.pearsonclinical.com/psychology/products/100000726/repeatable-battery-for-the-assessment-of-neuropsychological-status-update-rbans-update.html
Randolph, C. (2012). Repeatable battery for the assessment of neuropsychological status. PsycTESTS Dataset. Retrieved from http://www.pearsonclinical.com/psychology/products/100000726/repeatable-battery-for-the-assessment-of-neuropsychological-status-update-rbans-update.html ×
Willis, S., Tennstedt, S., Marsiske, M., Ball, K., Elias, J., Koepke, K. , … Group, F. (2006). Long-term effects of cognitive training on everyday functional outcomes in older adults. Journal of the American Medical Association, 296, 2805–2814. [Article] [PubMed]
Willis, S., Tennstedt, S., Marsiske, M., Ball, K., Elias, J., Koepke, K. , … Group, F. (2006). Long-term effects of cognitive training on everyday functional outcomes in older adults. Journal of the American Medical Association, 296, 2805–2814. [Article] [PubMed]×
Figure 1.

The Cognitive Skills Hierarchy

 The Cognitive Skills Hierarchy
Figure 1.

The Cognitive Skills Hierarchy

×
Table 1. Early Stage Dementia Cognitive Assessment Measures
Early Stage Dementia Cognitive Assessment Measures×
Brief Cognitive Assessment Tool A 20-minute assessment with 50-point total score
Subtests Include: orientation, immediate verbal recall, visual recognition/naming, attention, abstraction, language, executive, visuospatial, delayed verbal recall, immediate story recall, delayed visual memory, delayed story recall, story recognition
Repeatable Battery for the Assessment of Neuropsychological Status Update (RBANS® Update) A valuable initial or repeat test measure utilized as a stand-alone comprehensive assessment for the detection and characterization of dementia in the elderly. Subtests include: immediate memory—list learning and story memory, visuospatial/constructional—figure copy and line orientation, language—picture naming and semantic fluency, attention—digit span and coding, delayed memory—list recall, list recognition, story memory, and figure recall (Randolph, 2012)
Arizona Battery for Communication/Cognitive Disorders (ABCD) Standardized test battery for the comprehensive assessment of dementia patients. Includes 14 subtests that evaluate linguistic expression, linguistic comprehension, verbal episodic memory, visuospatial construction, and mental status (Bayles & Tomoeda, 1993) 
Cognistat Assesses neurocognitive functioning for many areas: level of consciousness, orientation, attention span, language, constructional ability, memory, calculation skills, reasoning/ judgment
Cognitive Linguistic Quick Test (CLQT) Assesses strengths and weaknesses in five cognitive domains: attention, memory, executive functions, language, and visual-spatial skills
Clock Drawing Executive Test (CLOX) Quick overview of visual neglect, planning, problem-solving, overall cognitive function. Also comprehension/attention to written vs. verbal directives. Measures executive control function (ECF). ECFs are cognitive processes that coordinate simple ideas and actions into complex goal directed behaviors. Examples include goal selection, motor planning sequencing, selective attention, and the self-monitoring of one's current action plan. All are required for successful clock-drawing.
Self Administered Gerocognitive Examination (SAGE) SAGE is a brief self-administered cognitive screening instrument to identify Mild Cognitive Impairment (MCI) and early dementia. Average time to complete the test is 10 to 15 minutes.
Assessment of Language-Related Functional Activities (ALFA) Organized into 10 subtests (understanding medicine labels, solving daily math problems, writing checks, etc.)
Burns Brief Inventory of Communication and Cognition Three Inventories—right hemisphere, left hemisphere, and complex neuropathology
Executive Function Performance Test (EFPT) Assesses cognitive integration and functioning in an environmental context. Unlike other tests of function, the EFPT does not examine what individuals cannot do. Rather, it identifies what they can do and how much assistance is needed to carry out a task
Test of Everyday Attention Measure selective, sustained, and alternating attention
Trail Making Test Test of visual attention and task switching/alternating
Personal History Interview Informal checklist of past and current occupational and leisure topics of interest that serve to motivate
Addenbrooke's Cognitive Exam (ACE-III) Brief, yet comprehensive, cognitive test with a maximum score of 100
Environment & Communication Assessment Toolkit for Dementia Care Comprehensive environmental analysis of visual and auditory stimuli in personal and public spaces
3 Words / 3 Shapes Test Subtest of auditory and visual memory (Mesulam, 1985)
Hidden Objects Test (informal) Informal, functional subtest of auditory and visual memory
Auditory and visual cancellation tasks To evaluate visual and auditory attention, concentration, organization, task approach
Table 1. Early Stage Dementia Cognitive Assessment Measures
Early Stage Dementia Cognitive Assessment Measures×
Brief Cognitive Assessment Tool A 20-minute assessment with 50-point total score
Subtests Include: orientation, immediate verbal recall, visual recognition/naming, attention, abstraction, language, executive, visuospatial, delayed verbal recall, immediate story recall, delayed visual memory, delayed story recall, story recognition
Repeatable Battery for the Assessment of Neuropsychological Status Update (RBANS® Update) A valuable initial or repeat test measure utilized as a stand-alone comprehensive assessment for the detection and characterization of dementia in the elderly. Subtests include: immediate memory—list learning and story memory, visuospatial/constructional—figure copy and line orientation, language—picture naming and semantic fluency, attention—digit span and coding, delayed memory—list recall, list recognition, story memory, and figure recall (Randolph, 2012)
Arizona Battery for Communication/Cognitive Disorders (ABCD) Standardized test battery for the comprehensive assessment of dementia patients. Includes 14 subtests that evaluate linguistic expression, linguistic comprehension, verbal episodic memory, visuospatial construction, and mental status (Bayles & Tomoeda, 1993) 
Cognistat Assesses neurocognitive functioning for many areas: level of consciousness, orientation, attention span, language, constructional ability, memory, calculation skills, reasoning/ judgment
Cognitive Linguistic Quick Test (CLQT) Assesses strengths and weaknesses in five cognitive domains: attention, memory, executive functions, language, and visual-spatial skills
Clock Drawing Executive Test (CLOX) Quick overview of visual neglect, planning, problem-solving, overall cognitive function. Also comprehension/attention to written vs. verbal directives. Measures executive control function (ECF). ECFs are cognitive processes that coordinate simple ideas and actions into complex goal directed behaviors. Examples include goal selection, motor planning sequencing, selective attention, and the self-monitoring of one's current action plan. All are required for successful clock-drawing.
Self Administered Gerocognitive Examination (SAGE) SAGE is a brief self-administered cognitive screening instrument to identify Mild Cognitive Impairment (MCI) and early dementia. Average time to complete the test is 10 to 15 minutes.
Assessment of Language-Related Functional Activities (ALFA) Organized into 10 subtests (understanding medicine labels, solving daily math problems, writing checks, etc.)
Burns Brief Inventory of Communication and Cognition Three Inventories—right hemisphere, left hemisphere, and complex neuropathology
Executive Function Performance Test (EFPT) Assesses cognitive integration and functioning in an environmental context. Unlike other tests of function, the EFPT does not examine what individuals cannot do. Rather, it identifies what they can do and how much assistance is needed to carry out a task
Test of Everyday Attention Measure selective, sustained, and alternating attention
Trail Making Test Test of visual attention and task switching/alternating
Personal History Interview Informal checklist of past and current occupational and leisure topics of interest that serve to motivate
Addenbrooke's Cognitive Exam (ACE-III) Brief, yet comprehensive, cognitive test with a maximum score of 100
Environment & Communication Assessment Toolkit for Dementia Care Comprehensive environmental analysis of visual and auditory stimuli in personal and public spaces
3 Words / 3 Shapes Test Subtest of auditory and visual memory (Mesulam, 1985)
Hidden Objects Test (informal) Informal, functional subtest of auditory and visual memory
Auditory and visual cancellation tasks To evaluate visual and auditory attention, concentration, organization, task approach
×
Table 2. Frequency of Treatment Clinical Decision Making Guide
Frequency of Treatment Clinical Decision Making Guide×
3x Lean Toward 3x/week ← Clinical Factors → Lean Toward 5x/week 5x
← Low - Medical Complexity – Acuity Level – High →
← Simple - Clinical Complexity – Multiple Treatment Procedures - Complex →
← Long Term Care - Discharge Setting – Home – ALF →
← Long - Estimated Facility Length of Stay – Short →
← Low - Patient Motivation and Participation – High →
← Low - Safety Awareness and Strategies as a Priority in Treatment – High →
← Appropriate - Spaced Retrieval / Higher Level Memory Interventions – Not Appropriate →
← Minimal - Rate and Amount of Weekly Progress – Significant →
Table 2. Frequency of Treatment Clinical Decision Making Guide
Frequency of Treatment Clinical Decision Making Guide×
3x Lean Toward 3x/week ← Clinical Factors → Lean Toward 5x/week 5x
← Low - Medical Complexity – Acuity Level – High →
← Simple - Clinical Complexity – Multiple Treatment Procedures - Complex →
← Long Term Care - Discharge Setting – Home – ALF →
← Long - Estimated Facility Length of Stay – Short →
← Low - Patient Motivation and Participation – High →
← Low - Safety Awareness and Strategies as a Priority in Treatment – High →
← Appropriate - Spaced Retrieval / Higher Level Memory Interventions – Not Appropriate →
← Minimal - Rate and Amount of Weekly Progress – Significant →
×
Table 3. Early Stage Dementia Cognitive Treatment Clinical Decision Making Guide
Early Stage Dementia Cognitive Treatment Clinical Decision Making Guide×
Points that drive the treatment program for persons with early stage dementia:
 • A valid reason for cognitive referral such as change in communication and/or cognitive status
 • Completion of a comprehensive evaluation with determination of the stage of dementia and the individual's new learning capacity
 • Identifying safety awareness skills particularly in activities such as cooking, driving, medications, money management
 • Development of a daily schedule, typical day to day roles, responsibilities related to communication and cognitive abilities
 • Selection of relevant treatment activities / personally influenced by interests, values and culture (this will insure a functional treatment program)
 • Determine individualized, effective communication and cognitive strategies
 • Educate and train all caregivers / family on effective strategies in order to discharge from SLP services with confidence
 • Significant or insignificant rate and amount of progress from week to week compared to short term goals
 • Consult with other rehab team members or medical staff on resolution of barriers interfering with treatment or needed follow up consultations impacting treatment
 • Identification of preserved cognitive or language based strengths (e.g. reading comprehension, clock interpretation, preference for visual cues) to determine if they are strong enough to assist in overcoming areas of challenge
 • Defining individualized quality of life
Table 3. Early Stage Dementia Cognitive Treatment Clinical Decision Making Guide
Early Stage Dementia Cognitive Treatment Clinical Decision Making Guide×
Points that drive the treatment program for persons with early stage dementia:
 • A valid reason for cognitive referral such as change in communication and/or cognitive status
 • Completion of a comprehensive evaluation with determination of the stage of dementia and the individual's new learning capacity
 • Identifying safety awareness skills particularly in activities such as cooking, driving, medications, money management
 • Development of a daily schedule, typical day to day roles, responsibilities related to communication and cognitive abilities
 • Selection of relevant treatment activities / personally influenced by interests, values and culture (this will insure a functional treatment program)
 • Determine individualized, effective communication and cognitive strategies
 • Educate and train all caregivers / family on effective strategies in order to discharge from SLP services with confidence
 • Significant or insignificant rate and amount of progress from week to week compared to short term goals
 • Consult with other rehab team members or medical staff on resolution of barriers interfering with treatment or needed follow up consultations impacting treatment
 • Identification of preserved cognitive or language based strengths (e.g. reading comprehension, clock interpretation, preference for visual cues) to determine if they are strong enough to assist in overcoming areas of challenge
 • Defining individualized quality of life
×
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