Dementia and Speech therapy
Vincent DelGiudice M.S. CFY-SLPVegas Voice Institute
Speech and Swallowing
Dementia affects not only a person’s memory, but their ability to use language.Speech therapy can help with strategies for memory and conversational success.On the lesser known side, dementia also affects a person’s ability to swallow and enjoy a meal, which leads to a decrease in the quality of life.Swallowing therapy can help provide strategies to be a safe eater and allow caregivers to feel less stress during meals.
Despite the estimation that there will be a prevalence of 42.3 million people worldwide with dementia in 2020, there is limited research in the area of dysphagia and dementia.Dysphagia refers to the swallowing difficulties that occur in the oral cavity, pharynx, and/or esophagus.This can lead to dehydration, malnutrition, weight loss and aspiration pneumonia.Dysphagia can be evaluated by a speech pathologist by either aFiberopticEndoscopic Evaluation of Swallowing(FEES) or Modified Barium Swallow Study(MBS).
Hallmark symptoms associated with types of dementia
Alzheimer’s Disease: Sensory aspect – associated with decrease in a/p oral transit time.Decrease in sense of smellVascular Dementia: Motor aspect – associated with poor bolus control.Frontotemporal Dementia: Tendency to eat rapidly and compulsively with larger boluses.
Compensatory strategies vs. Rehabilitative exercises
Compensatory StrategiesRedirect the follow of the bolusDo not change the level of function of the swallowInclude postural changes, modification of bolus volume, consistency, temperature, and rate of bolus presentation
Rehabilitative StrategiesStrengthen muscles associate with swallowingIncrease swallow reflexIncrease airway closure and protection for swallowing
Postural Changes and compensatory strategies
Compensatory StrategiesChin TuckIncreased time to initiate swallowSupraglottic SwallowProtects airway before swallow
Postural ChangesSitting at a 90 degrees.Alert and OrientedCheck Oral Cavity for pocketing
Last possible course of actionLeast restrictiveFood: Regular, mechanical soft, pureed, and liquidLiquids: Thin, nectar, honey and pudding.A speech pathologist will evaluate the need for each modification during evaluation.
Masako ManeuverBite tongue with front teeth, hold in place, and attempt to initiate swallow.Mendelsohn ManeuverFeel for your thyroid notch (adam’sapple), swallow and feel elevation and excursion. Now on your next swallow, when your thyroid notch raises, squeeze your laryngeal elevation muscles to hold up your thyroid cartilage up for 3 seconds.Shaker ManeuverLay on a flat surface and raise head up and hold to your chestValsalva ManeuverBear down and push vocal folds together
More successful conversational strategiesReduced caretaker burdenImprove QOLMaintenance of language abilitiesKnowledge of AD and understanding communication breakdowns.
Educating the caregiver about dementia and communication can be more important than therapy with a patient.Caregivers are with the patient 24/7 and know what problems they deal with on a daily basis.Often caregivers come to speech hoping that sitting in the room with a speech pathologist for 40 minutes to an hour is going to help them.Educating families, staff of nursing homes, memory units, and the general population.Working as a team with these populations and including the family and/or caregivers is detrimental to success in communication.
Strategies for supporting feeding, hydration, and enjoying meals
Good Oral HygieneConsistent Environment during mealtimeEncouraging more small meals and drinks throughout dayIncluding different tasting foods to maximize sensory inputDieticianEncouraging self-feeding
Focusing only on eating while at mealsDecreasing distractionsTaking nonfood items from tableMaking food look appealingAllowing patient to eat with hands or touch foodDecreasing wait time between sitting at table and eatingProviding choices
Discussing this with patients and their families early on is important.Patients need to make these decisions or choose someone to do so before late stages of dementiaFeeding tubes are important because it bypasses the upperaerodigestivetract which should in turn decrease the chance of aspiration pneumonia.Recently research has been showing that there PEG tube placement puts patients at greater risk for aspiration pneumonia.Patients often have to be restrained so that they do not pull out PEG tube, which causes distress and lack of comfort for the patient.
Impacts on Communication
AttentionLearning and MemoryReasoning and Executive FunctioningPerceptual AbilitiesLanguageSocial Cognition and Behavior
Communication options for speech therapy
Cognitive Stimulation therapyEnvironmental ModificationsExternal Memory AidesMemory Training ProgramMontessori-Based TreatmentReality OrientationReminiscence TherapySimulated presence therapyValidation Therapy
Functional and face-to-faceOrient to TopicContinuity of topic and concrete topicsUnstick any communication blocksStructure with yes/no and choice questionsExchange conversation and encourage interactionDirect, short, and simple sentences
During speech therapy we attempt to have successful interactions and communication between patient and therapistConcrete subjects such as a picture to look at, a video to watch, questions about a paragraph or reading in front of them.We challenge the memory of the patient with memory recall tasksDigit and word recallPicture recallName-picture associationProvide compensatory speech strategies such as memory booksMemory books allow patients to use reminiscence to reorient.
Provide memory strategiesChunking methodDetail orientedAcronymsLists, calendars and schedules
Families and/or patient having unrealistic goalsLack of carry-over from prior sessionsLack of caregiver help/observation during the sessionLack of knowledge about the course of the diseaseDepressionFrustrationApathyDay-to-day changes
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