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TherapyTravelers - September 2018

Brain Health Basics: Strategies for SLPs to Supporting Healthy Aging for Adult Patients

Brain Health Basics: Strategies for SLPs to Supporting Healthy Aging for Adult Patients
September 30, 2021

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Editor’s Note: This text is a transcript of the course, Brain Health Basics: Strategies for SLPs to Supporting Healthy Aging for Adult Patients, presented by Megan Malone, MA, CCC-SLP and Jennifer Loehr, MA, CCC-SLP.

Learning Outcomes

After this course, participants will be able to:

  1. Describe why brain health education & instruction are important aspects of care for SLPs working with adult patients.
  2. Provide at least two key areas that should be supported as part of brain health education for patients.
  3. Describe how an SLP can provide brain health education to support community outreach.

Introduction: What is Brain Health?

This is a very basic introduction to brain health, what it is and what role the speech-language pathologist can take. So, what is brain health? If you do a Google search on brain health, there's a phenomenal amount of information available as it is a trend now in the United States and other parts of the world.

The US Centers for Disease Control Prevention define brain health as an ability to perform all the mental processes of cognition, including the ability to learn and judge, use language, and remember. The American Heart Association/American Stroke Association presidential advisory defined optimal brain health as “average performance levels among all people at that age who are free of known brain or other organ system diseases in terms of decline from function levels, or as adequacy to perform all activities that the individual wishes to undertake (BMJ, 2020).” Essentially, it's being able to function normally throughout our lives and particularly as we get older.  I like to remind everyone that cognitive decline is really not a normal part of aging. That's not something that we should actually expect. We expect to be healthy - healthy bodies and healthy brains - as we get older. But that doesn't always happen.

Brain health refers to how well a person's brain functions across several areas. These aspects include:

  • Cognitive health - how well you think, learn and remember
  • Motor function - how well you make and control your movements including balance, walking, et cetera
  • Emotional function - how well you interpret and respond to emotions, both pleasant and unpleasant
  • Tactile function -  how well you feel and respond to sensations of touch, including pressure, pain, and temperature

Brain health can be affected by age-related changes in the brain, injuries such as stroke or traumatic brain entry, mood disorders such as depression, substance use disorder or addiction, and diseases such as Alzheimer's disease.  While some factors affecting brain health cannot be changed, there are many lifestyle changes that might make a difference (National Institutes on Aging, 2021).

Again, there's a nice trend that we're seeing now in that we're realizing we can be proactive and play a part in keeping ourselves healthy and active into the later years of our lives.

Alarming Statistics

It is great to see this awareness because there are some very alarming statistics:

  • People are living longer and by 2030 about one in five Americans will be aged 65 and older. If you're in the business of working with older folks, I think you're in the right place for a while.
  • Older adults are at significant risk of having multiple chronic diseases, also known as co-morbidities and multi-morbidities, and associated functional impairment.  The older we get, the more we are prone to diseases and illnesses, and it compounds as we get older and get sicker.
  • Approximately 5.7 million people in the United States currently have Alzheimer's disease. The number of Americans with Alzheimer's is projected to triple to 16 million by 2050 (Alzheimer’s Association, 2021).
  • Three out of five Americans will develop a brain disease in their lifetime (American Heart Association, 2021).
  • Neurological conditions are the leading cause of disability and the second cause of death globally accounting for 9 million deaths per year (WHO, 2021).
  • 34.1 million adults in the US currently smoke cigarettes. More than 16 million Americans live with a smoking-related disease, which is astounding to me (CDC, 2020).
  • In 2018 the age-adjusted prevalence of obesity in adults was 42.4% (CDC, 2020). That’s quite a bit.
  • Failing brain health is a public epidemic (American Heart Association, 2021). That is actually a quote from the American Heart Association.

Subjective Cognitive Decline

I also wanted to provide some information on Subjective Cognitive Decline, SCD. This is self-reported cognitive decline or confusion et cetera. It's not individuals who have a formal diagnosis of dementia or Alzheimer's disease, rather it's their own perception of their cognition. It is self-reported experience of worsening or more frequent confusion or memory loss within the past year. It's a form of cognitive impairment and one of the earliest noticeable symptoms of more severe memory disorders such as Alzheimer's disease and related dementias.

Subjective Cognitive Decline can have detrimental implications for living and managing chronic diseases or performing everyday activities like cooking or cleaning.  When cognition is impaired, it can have a profound impact on an individual's overall health and well-being (Centers for Disease Control and Prevention, 2021).  I mention this because patients or individuals that you work with don't necessarily have to have this formal diagnosis of dementia, there are a lot of folks who have a subjective cognitive decline as well.

The Role of the SLP

As SLPs, what is our role with brain health? I think this is a perfect profession to deal with issues surrounding brain health. The following information comes from the American Speech-Language-Hearing Association. It discusses the role of the speech-language pathologist in general, and we can take this information and use it with individuals to educate and promote brain health and prevention of cognitive decline.

  • Article II of the ASHA Bylaws states that one of the “…purposes of this organization shall be to…promote investigation and prevention of disorders of human communication…”
  • There has been a national emphasis on disease prevention and health promotion, and speech-language pathologists and audiologists have broadened their view of prevention of communication disorders.
  • Prevention requires increased efforts to eliminate the onset of communication disorders and their causes and to promote the development and maintenance of optimal communication.

It is the position of ASHA that SLPs and audiologists should:

  • utilize consistent terminology related to prevention
  • play a significant role in the development and application of prevention strategies
  • expand research into the causes of communication disorders and variables that influence the development and maintenance of communication abilities
  • educate colleagues and the general public relative to personal wellness strategies as they relate to the prevention of communication disorders

SLP Scope of Practice

Again, with regard to brain health and the scope of our practice, we are charged with collaboration and are responsible for counseling. We are also responsible for prevention and wellness of our patients, in addition to our other duties such as screening, assessment, treatment, modalities, technology, instrumentation, et cetera. 

There are additional domains that are delineated to our scope of practice from ASHA and that's advocacy and outreach, which is a really big piece of the brain health programming that we are talking about in this course, as well as education, research and administration.   SLPs are also involved in prevention and wellness activities.

Essentially all of this information from ASHA is justifying your involvement in brain health programming, educating patients, family members, and the public on brain health, and playing a big role in prevention.

Additionally, our involvement is directed toward individuals who are vulnerable or at risk for limited participation in communication, hearing, feeding, swallowing, and related abilities. Education efforts focus on identifying and increasing awareness of risk behaviors that lead to communication disorders and feeding and swallowing problems. SLPs promote programs to increase public awareness, which are aimed at positively changing behaviors and attitudes. Effective prevention programs are often community-based and enable the SLP to help reduce the incidence of spoken and written communication and swallowing disorders as a public health and public education concern.

As I mentioned before, we are in the perfect profession to be educating and promoting brain health among our patients, their family members, and the community at large.  We have to be proactive versus reactive when we can. We know that we have to be engaged and help our patients when they receive a diagnosis and then assess and treat as needed. But the more that we can be involved in prevention before they get to the point of needing us for treatment, that can be so helpful.  Providing adequate education helps them take better care of themselves and their own health so that they might not need us quite as much in terms of treatment.  We all want to see our patients move on and not need us as much.  That means that we're doing a good job and they're progressing, which is always the goal.

Fundamentals of Brain Health Education

Let’s move on to discuss the fundamentals of brain health education. There are many different resources related to brain health and we want to summarize a few of them here:

  • Georgetown University Medical Center: 4 Pillars Program (Turner, et.al, 2019)
  • Healthy Brain Initiative (CDC, 2020)
  • AARP Staying Sharp Program (AARP, 2021) - Has a subscription option for people to join to have better connections with resources, including ways to exercise their brain through different cognitive tasks, et cetera.
  • Cleveland Clinic Six Pillars (Cleveland Clinic, 2021)
  • The Brain Health Project (Center for Brain Health, 2021)
  • Global Council on Brain Health (Global Center for Brain Health, 2021)

Physical Exercise

What are the key elements these programs focus on when providing brain health education? The first one is physical exercise. These programs look at the overall health of a person, not just the brain. How does the overall health of the body make a difference in how the brain functions? Physical exercise is always a recommended part of that. We know that exercise improves blood flow and memory. It decreases the risk of developing Alzheimer's disease. It stimulates chemical changes that can enhance mood, learning, and thinking (Cleveland Clinic, 2021; AARP, 2021).

It is always recommended to get up and get moving, even a little bit if you can.  Of course, that's limited by how physical the person can be. However, there are many options such as taking further steps through the home during the day, doing chair exercises, yoga, or Tai Chi; anything that allows them to move a little bit more. Many people have a limited idea about the purpose of physical exercise. We hear, “I want to lose some weight,” or “I should get moving a little bit,” or, “My doctor tells me I should do this.” But sometimes it's a little lost on people about how exercise can actually affect the brain because you're getting that blood pumping.  We also often hear that heart health, cardiovascular health, equates with good brain health. So, anything that you can do to help your heart is going to be fundamentally helpful to your brain.

Food and Nutrition

Eating more nutritious foods can reduce oxidation of brain cells, provide more energy, and support all systems of the body. The better we eat, the better we're going to feel. We all know this. Do we do it all the time perfectly? No, but some of our older patients may have limited access to fresh foods. Maybe they're doing less cooking on their own, and they might have some hesitation about that.  Maybe they have financial limitations and are nervous about the price of some of the fresher foods that are available so they opt for something that's in a box because it is cheaper.

As SLPs, we can help our patients change their way of thinking.  We could say, “Sure, go and have the can of soup, but maybe have a small salad or some fruit afterward." “Swap out the diet Coke here and there for water.” Those types of suggestions can help them understand that not only is that going to make them feel better, but it may actually help them improve some of their cognitive health, which is a great bonus.

Healthy Heart

Again, a healthy heart equals a healthy brain. This can mean controlling blood pressure and diabetes, stopping smoking, increasing exercise and healthy eating.  If we can get people to think about taking better care of their hearts, we might see some changes happen with their brain as well.

Medical Health

We want to control medical risks. We want to recommend that people get regular checkups and manage chronic diseases. We want to encourage our patients stay on top of their medications, reduce alcohol intake, stop smoking, and reduce the risk of brain injury by discussing fall prevention. Finally, we want to encourage them to maintain dental hygiene because, as we know with a lot of our dysphagia patients, that can be a really big part of being able to stay healthy.  It is so important to have good dental hygiene, keep dentures clean, get regular dental visits to reduce the bacteria that may be in the mouth and possibly get into the lungs, etc. if someone is showing signs of compromised swallowing.

Again, oftentimes people don't think about any of this until they start to have a problem or they see a loved one who's dealt with something like Alzheimer's disease or dementia. Then they might have some questions. But as we know, most of our patients don't really question how, for example, swallowing might relate to the possible functioning of the rest of their body.  If we can talk about this in a preventative way, that opens up people's minds and helps them make connections maybe they never had before.

Sleep & Relaxation

We all know sleep is important. None of us get enough of it, but it is so important and can make a great difference in how we function cognitively. Sleep provides us with more energy, better mood and immune system, and reduces build-up of beta-amyloid plaque that is associated with Alzheimer's disease. Sleep can also help with managing stress and age-related decline in brain health and mental health.

We want to encourage people to get the rest that they need.  If they tend to wake up several times in the night, how can we work with them to figure out what's happening? Are there underlying anxiety issues that might keep them up worrying at night? Do they have to use the restroom quite a bit? Is there a way we can work through that or look at what their liquid intake might be before bed? How can we make these recommendations so they can improve their sleep, which is going to help them improve their thinking and decision-making the next day?

Mental Fitness

Mental fitness is a hot topic right now.  How can we keep our brains strong by doing exercises that help the brain? There is evidence that shows that mental exercise can definitely help keep the brain sharp. It can improve brain functioning and promote new brain cell growth. It can decrease the likelihood of developing dementia. There's a lot of great research that points to the fact that keeping mentally fit, keeping sharp, doing something new, and learning throughout your life is going to help keep your brain healthy.

We're looking at brain plasticity. How can we physically change the brain through learning and experience? We can also consider cognitive reserve which is the brain’s ability to improvise and find alternate ways to get a job done. Our cognitive reserve starts early in life.  The more you're learning, the more curious you are,  the more you educating yourself, the more you are changing up what you're doing and having different experiences, that's what is referred to as cognitive reserve. It helps your brain to form more pathways, have more resilience. Research is finding if you have cognitive reserve, that can stave off the diagnosis of degenerative brain disease. Therefore, the more we're able to do earlier in life, the better off we're going to be later in life.

Again, we might be educating a lot of older adult patients or family members, but don't hesitate to educate younger adults.  Any of our adult patients would benefit from understanding how they can keep themselves healthy. It's going to be better for them in the long run and it really fits that role of prevention that we're looking for as SLPs.

Social Interaction

We know that an active social life can lead to better brain health. Staying connected with others may slow the rate of memory decline. We want to encourage patients to stay knowledgeable and take action. If a patient knows something's different or feels “off” tell them to take action and ask about it.  Encourage people to not be afraid to ask better questions about their health. Many of us want to believe “no news is good news” and that can be a dangerous place to be. Then when something does finally go wrong, it may be too late to provide a more successful intervention.  So, it’s important to tell our patients that it is okay to ask questions. That doesn't mean they're automatically going to be put in a nursing home or their car keys are going to be taken away. It just means that they're being proactive about changes they might be seeing.

Those seven areas are the key elements that we find across most brain health programs. They are going to be the bedrock of what we're talking about related to the education of our patients and families and how we can embed these things into our treatment with patients.

MCI and Dementia Prevalence

There are a few key points that are fundamental to brain health education. One is MCI and dementia. A lot of us might be seeing patients with dementia or possibly mild cognitive impairment diagnosis. MCI causes cognitive changes that are serious enough to be noticed by the person affected and by family members. However, those changes don't necessarily affect the individual's ability to carry out everyday activities.

With dementia, we start to see people struggle every day with a lot of their daily functional activities. In cases of MCI, things are starting to change a little bit, but people are still basically able to do what they need to do. We want to keep that in mind because a lot of brain health types of education and exercise can be helpful in working through MCI and can help stave off the progression of something bigger if we get involved sooner and provide good, strong education.

Additionally, older adults are at an increased risk for depression. About 80% of older adults have at least one chronic health condition, 50% have two or more, and depression is more common with people who have other illnesses. That’s a pretty big percentage that we're seeing with older adults living in the community who may have some type of mental health issue, particularly depression in this case. Going back to those fundamentals, that idea of socialization,  getting endorphins moving with some physical exercise, eating better, sleeping and getting the appropriate rest, and feeling more confident about cognitive skills, those factors can help with working through some of those depression issues. Of course, we are not going to diagnosis depression.  We're always going to turn to mental health professionals related to that. But we want to keep in mind that a part of brain health is working with mental health, and providing brain health education may help our patients who are dealing with some mental health issues.

Some research has been conducted related to brain health. The ACTIVE Trial wrapped up around 2010.  This is the Advanced Cognitive Training for Active and Vital Elderly and included healthy adults aged 65 and older who participated in 10 sessions of memory training, reasoning training, and process speed training.

The sessions focused on memory training (mnemonics for recalling verbal material), reasoning training (identifying next item in a series) speed of processing training (computer-based, visual search and divided attention tasks). These are some of same the cognitive exercises that were mentioned earlier. They focused on specific training related to the different cognitive areas for this study and had the older adults participate in approximately 10 sessions to see if it made a difference. The researchers found that the sessions improved participants' mental skills in the area in which they were trained with evidence suggesting that these benefits persisted for two years.

Again, if participants became more active with these tasks, the active trial shows that some of the effects of the exercises lasted for about two years, which is significant.  Pushing off those bigger issues in life can affect a person's independence, safety, et cetera. The more that the participants were able to do these activities and participate, the better off they were even two years post. Additionally, the groups that participate in cognitive training also demonstrated less cognitive decline compared to the control group.

This study provides some good evidence that doing these exercises can be helpful and getting involved at any stage of life might be something that we want to encourage in order to see people stay healthier for a longer period of time. 

Strategies to Incorporate Brain Health into the SLP POC

How can SLPs include this information in the plan of care (POC) and goals for our clients?

For developing a plan of care, one of the most impactful tools for a speech-language pathologist no matter the setting, the clientele, or the age group, is the International Classification of Functioning, Disability and Health, also known as the ICF.  It was developed by the World Health Organization a long time ago as a model for developing a plan of care.

Many health organizations have adopted it, including ASHA, APTA, and AOTA.  All of our associations now state that we should be using the ICF to develop plans of care for our patients because it's a holistic approach to taking care of the patient. The model doesn’t just include the health condition that we're working with (e.g., Alzheimer's disease or stroke, et cetera).  We're not just looking at that ICD-9 code. We are encouraged to go beyond and look at all of those factors that impact a patient's functioning. Ultimately, we're trying to get our patients to function as independently as possible, whether that be related to issues of cognition, swallowing, language communication, etc.

We need to look at the patient currently and in the future.  We look at how the health condition affects the functioning of the body and the structures (i.e., impairments). We look at how that then affects activities (i.e., limitations) and how are they are limited because of the health condition, body function, and structural impairments.  Then we also need to look at environmental factors that are going to impact the patient's functioning.

Some great examples were given earlier about factors that may be creating depression, such as social isolation.  In home health, since the pandemic and doing ride-along visits with a speech-language pathologist, we have been seeing a phenomenal increase in the amount of isolation that's causing depression and subsequent other problems in our elderly patient population. Therefore, we absolutely need to look at environmental factors that are going to impact and affect the plan of care.

There are also personal factors to consider. Who is this patient?  What's important to them? How can we get them to be functioning as the person that they are and with the type of things that are important to them?

ICF Example

Here is an example of what each of these items in the ICF relates to. The health condition could be, of course not limited to, CVA with aphasia. Body function impairment is that the stroke affects the neurological system and/or the cardiovascular system.  It could affect the musculoskeletal system in that it is affecting the person's movements and tactile functioning, et cetera.  Activity limitation means the CVA and the aphasia affects a person's ability to think, speak, and communicate their basic wants and needs, their mobility, and/or their swallowing.

How does the stroke affect participation? It will create challenges with making appropriate decisions, communicating socially, ambulating, and/or maybe getting transportation so that they can get food or get to their medical appointments.  

Environmental factors may be limited transportation options for this individual or living in a cluttered living environment. I've seen that a lot.  In the home health world, there is a lot of hoarding going on with individuals who have been shut in because of the pandemic. 

Another environmental factor is the patient’s motivation to get better which is more of an attitudinal environment. Maybe the patient has a spouse. If the spouse is the caregiver and has a limited education, that is definitely going to affect how we structure and organize a brain health program for the patient and the caregiver.

Again, it's not just the physical environment, it is the attitudinal environment or social-economic environment. There may be limited finances that are impacting our ability to get the patient from point A to point B.

Lastly, one of the most important aspects of developing a plan of care is their life participation.  Who is this person? Let's say that this patient was a deacon in the church and for years was very active in the church. Well, we want to build that into our plan of care with regard to brain health, being healthy physically, and being able to function. We want them to be able to get back to being the person that they were before.

As we all know, especially after a stroke, it's not always possible to get back to 100% functioning the way you were before. I believe that a person who's had a life-altering event like a stroke will never be the same person that they were before.  However, there are steps that we can take and we can modify their activities. For example, we can maybe bring the important activity to them. There are other life participation roles to consider. Maybe a patient’s whole purpose in life is to play bingo at the bingo parlor or maybe their whole purpose in life is to be a grandparent. We need to include that in developing a plan of care.  That's really going to help us when we are developing a brain health program for our patients.

Educating on Threats to Brain Health

The SLP’s role is definitely education and part of brain health education is educating the patient on the threats to brain health.  Again, we're not just treating the aphasia or the stroke or the dementia.  We are also responsible for mitigating or preventing future decline.  How wonderful it would be if we could not only help the patient communicate better or swallow better but also prevent them from getting sicker or having another event.

Some of the topics that we can include in our treatment are:

  • Good vs. Poor Food Choices – maybe choosing a salad instead of a cheeseburger. A cheeseburger is ok once in a while but not all of the time.
  • Negative Effects of Smoking
  • What Physical Exercise Can Do for the Body
  • Benefits and Strategies of Getting Good Sleep – Sleep is very important and very few of our patients get good sleep.  Some of that is related to the pharmaceuticals, some of it is related to depression, anxiety, etc.
  • Why Should We Monitor Blood Pressure? – We can assist the patient in how to monitor and document their blood pressure readings
  • The Benefits of Meditation, Relaxation, and Deep Breathing – You don’t have to be a yoga instructor to teach the fundamentals of relaxation.  Deep breathing exercises are wonderful for our patients to help get the oxygen flowing, to help calm and relax them during the day, etc.

These are all great items to educate patients about good brain health and preventing future events.

Infusing Brain Health into Therapy Tasks

What are some activities that we can do as SLPs while working with our patients during therapy?  You can take breaks in between therapy tasks to educate on those items described above or you can infuse brain health into the tasks that you're doing when you're with a patient.

One idea is to use flashcards with patients. I like making my own flashcards, so why not incorporate brain health ideas into them. For example, instead of just everyday common objects, maybe focus on food items that are healthy food choices. There is a multitude of cognitive tasks that you can do with healthy diet flashcards.

Another idea is to incorporate the use of the facility menu and meal choices into expressive language tasks. If your patient lives in a facility, use the facility menu and infuse the education of what good meal choices are and what good food can do for the body and brain.

We can have the patient follow a multi-step cognitive activity involving menu planning, or simple meal or snack preparation while educating on healthy choices. 

We can incorporate relaxation breathing techniques into therapy. I do this as much as possible with my patients, especially patients who have voice disorders.  It's also really helpful for patients who are suffering from anxiety to learn how to regulate their breathing and identify when they are starting to feel anxious. We can teach them what is shallow breathing and what is deep, calm, relaxed breathing.

Additionally, we can give the patient choices for “brain exercises” to do for homework each week.  To improve that cognitive reserve, we can encourage our patients to do something different every day that is going to help grow the brain. We can have our patients make choices for different types of activities that are going to promote brain growth by just doing a different exercise every day. They can do a different puzzle, a different type of language activity, or a crossword puzzle activity.

I always like to have my patients do something functional in a different way every day, to helps the brain as well.  It doesn't have to be something grand. For example, challenge your patient to put on their shoes opposite of what they're used to doing. If they always put on their right shoe first, challenge them to put on the left shoe first. If you try it yourself, you’ll see that it's not as easy as it sounds. It takes some brain work to do something different every day. Another example is to challenge the patient, and you can be with a patient if they're in a facility, to find a different route to go to the dining room, or to the bingo room, or to the activity room. It takes a lot of brain activity to find a different route and to problem solve.

We can provide the patient and/or caregiver education regarding lifestyle choices (e.g., exercise, smoking cessation) and incorporate goals to help the patient learn how to access online fitness classes or brain exercise programs. Finally, we, as SLPs, can play a great role in developing activities for the patient that help them get in control of their own medical health. For instance, teaching them to use a calendar to keep track of appointments or keeping track of their brain health exercises in a log or calendar.  They can learn to track their own blood pressure and then record and report those readings to the physician. Those are all problem-solving tasks with regard to taking control and taking care of their own medical health and avoid or mitigate the decline of their medical health as well.   

Develop Goals

It's important to always be cognizant and aware of goals and it is fairly easy to incorporate brain health goals into your plan of care.  Brain health goals may be in addition to the goals that you're writing for cognition and communication, or you can infuse brain health into the plan of care. Here are some examples:

  • Patient to demonstrate understanding of heart-healthy diet as evidenced by (this is a very important phrase that we should try to add into our plans of care as much as possible) making healthy food choices from the facility menu
  • Patient to follow instructions for relaxation techniques as evidenced by
  • Patients to complete one “brain game” exercise per day
  • Caregiver will demonstrate understanding of healthy diet instruction as evidence by teach-back
  • Patient will complete a personal journal to track diet, exercise, and sleep patterns

Team Collaboration

Finally, the most important piece is collaboration.  We can utilize all team members. Everybody can get on the bandwagon. Think of how impactful it would be for the patient to have good brain health and to be part of a brain health program with all of the other team members playing a part in it.

We are collaborating with the physical therapist with regard to the exercises and collaborating with physicians to determine the best dietary choices. We are collaborating with the social worker to provide referrals for community services, not just with regard to substance abuse or alcohol addiction, but maybe it's with regard to transportation options for the patient to get them back to church because that's the person that they are and that's the person they want to be.  We can collaborate with the facility to expose the patient to community events, activities, social functions, and collaborate with the care team in general to establish a consistent approach to teaching education for the patient and the caregiver.

Creating Brain Health Programs

As mentioned earlier, I'm a clinical faculty member at Kent State. In 2013, a colleague and I decided we needed to do more public outreach related to brain health to help some of our community dwelling older adults. Plus, we saw a hole in our program in terms of exposing some of our students to working with older adult clients sooner in their program. We really wanted to encourage students to think more about working with adults, take away some of the fear that they might have about working with that population and be able to provide a service. So, we decided to create a brain health program for seniors living independently in the community. Again, we developed it to provide the brain health education as a preventative measure to assist older adults in making more informed choices regarding their health as well as providing cognitive stimulation through group discussion and activity-based learning.

Program Details

We decided, based on semesters, to make the program about eight weeks in length. We had about six to 10 participants in a group and we met one time a week for an hour. Initially, we had two facilitating SLP graduate students who ran the groups and we provided the students with a general format to follow. However, they were allowed to customize the program based on the makeup of the group and the needs determined during participant evaluations, etc.

Initially, we decided we wanted to work out in the community because we work with people who have limited transportation and having them come to our university clinic was going to be challenging. So, we thought we go to them, it would be free, and we would provide food.

We found some apartment complexes for 55 and older adults in the area and started announcing that we were going to provide this program. We did some brief introductory presentations with some food provided, a healthy snack and some water with the idea of exposing them to healthy choices right out of the gate.

We played some fun cognitive games as icebreakers so they could get a preview of what we'd be doing. People were, naturally, a little suspicious about what it would be so we wanted to make it fun. We told people they could come and just sit and observe if they wanted to. They didn't have to participate. We were just trying to expose people to what the possibilities would be.

Then we did cognitive evaluations with all the interested participants.  We would do full cognitive evaluations mainly to give the students some of that exposure, but also to give people a baseline to start with how they were doing. 

Initial Evaluation

The initial evaluation included a case history and either the CLQT+ or the RIPA-G.  We administered the MoCA or the SLUMS as another way to screen for cognitive abilities. We also gave the Geriatric Depression Scale, short form.  We talked about how important mental health is for this population so we wanted to see how people were doing or if they need some referrals. Also, a program like this might help increase their socialization and give them a little more confidence so we wanted to see if we made any changes related to that by the end of the program.

We also gave the Space Retrieval Screen which is a cognitive intervention that can be used to help people remember information better. We wanted to see if it was something we could infuse into either our sessions or as recommendations for patients to use to help them remember important information.

We administered these tests at the start of the program, and then at the end of the eight weeks, we followed up with the MoCA or the SLUMS again depending on which one they were given initially.  We always gave the GDS again.  We were obviously interested in seeing if there were any changes as a result of participating in the group and provide people with information about how they're doing.

Results

As a result, many participants demonstrated improved post-test scores on cognitive measures and on the GDS Short Form. It was excellent to see that people were feeling less depressed as a result of coming to the program. Was it only because of the program? Who knows? The GDS only looks at about a week or two weeks intervals, but I think it did have an impact because the participants would express that it did.

A lot of the participants built new relationships with people they didn't even know in their building before and now they were engaging with them weekly. They started meeting for game nights and checking in on each other. They'd participate multiple times in the group if we went back to a facility.  We've seen people report changes in their eating habits and making better choices.  Additionally, the students showed some great gains in their knowledge level of working with older adults.

Examples of Weekly Themes:

We conducted weekly themes related to brain health such as attention, problem solving, memory, word finding, etc.  The students would talk about the different themes and then do a group activity. 

We would have a healthy snack and educate the residents about different ways that they could find ingredients for the snack in their grocery stores. The students would shop for the ingredients and provide the recipe to the participants. We were trying to make it as easy as possible for the participants to utilize what they learned at a later time.

We also spent some time asking participants what they wanted to know. Many of them had very big concerns about what the difference is between dementia and normal aging changes or just slight forgetfulness.

We would add some fun activities like hydration challenges. For example, they all had a bottle of water and we would challenge them if there was a picture of a cup of water on the slide that the students were presenting, then they had to take a drink.  Or if they saw someone in the group take a drink, then they had to take a drink.  We would also mark on their water bottles where they should try to get to by the end of the session.  It was just a way to make these healthy habits more fun and they could be supportive of one another.

We would do some meditation, breathing or stretching. We always started the group that way and even do it part way through as a way to reset and let people know that this is something they can easily do throughout their day. Even if you're doing a challenging task, taking a little break and stepping away might help you reset so you can finish what you're doing.

Again, “brain food” activities included some fun snacks and education on the benefits of different ingredients.  For example, we discussed the water content of celery (which is shocking).  We would have a healthy snack of celery with peanut butter and raisins, and most people think celery is one of those throwaway foods. But the amount of water content in it is really great and is, therefore, a great way to keep up with hydration. 

Other activity examples include:

  • Attention: Crafts that required following multiple steps (in presence of distractions)
  • Problem Solving: Building towers out of given materials in small groups; using local bus maps to complete given errands; using local grocery store circulars to determine best prices for needed items for a recipe
  • Word Finding: “Escape Room,” answer different word/category clues to lead to next clue
  • Executive Functioning: Planning a party given different constraints
  • Memory: Recall shopping lists using chunking; using spaced retrieval for recall of given information

We would work on crafts and then add distractions, music, etc. to see if participants could divide their attention and use some of the strategies that were taught as part of the lecture. We would put people in teams and give them things to build out of materials, give them local bus maps to complete errands, or give them local grocery store circulars to determine prices for items.  The idea was to have them challenge each other and work together to complete some of these tasks.

The students came up with a great idea of an “escape room” to work on word finding. The participants had to work through a riddle or a clue that would lead to another clue. The participants really enjoyed this escape room concept.

How Can the Program Be Adapted?

You might be thinking this program sounds great but you don’t work at a university and you don’t know how to implement something like this.  However, you could provide short informational sessions on brain health to the residents at your facility or a senior center.  You could even recommend that idea to your agency or facility.

Being more prevalent in the community can ultimately help with admissions and referrals, and it also shows that you're really looking out for the community at large, which is great. You could partner with another department to provide variations of the program monthly to residents or to family members. You could offer the program to larger groups or set up smaller groups with assistance from volunteers.  Maybe you start small with a few presentations here or there, and then maybe family members want to start helping out.  They could be trained on some of the activities and you are available to oversee that. 

Also consider including some elements of brain health education in your patient sessions, home visits, or group treatment.  Although the original program was in an ideal setting like a university, you can take some of these examples and inspiration from what we learned in the group and apply it to what you're doing in your setting.

Creating brain health programs can improve community outreach and support and increase community understanding of speech-language pathology. So many people don't know that we work with this and what our role is in terms of working with cognition or brain health.  We want to put it out there and let others know about other things that we do.

You might see an increase in referrals for your services because these programs can help to differentiate your workplace from others.  Additionally, they are a good marketing tool and excellent opportunity for a student project. If you have students at your facility, this could be something you can get them to think about. This might even be a good intergenerational opportunity for people to bring their grandkids in and work on some of these projects. Then, they can all be working on attention or solving a problem together.  That’s a much different visit than coming in and asking Grandma how she's feeling and what she ate today.

Brain Health Resources

Questions and Answers

Can you review the idea of hoarding as it relates to mental health?

We may see hoarding behaviors be more prominent if people are having some mental health issues. It doesn't mean that everybody's going to be that way, but it could be something that is more prevalent. With the pandemic, there has been an increase in that behavior with some patients in home care.

Can you provide a brief description or instructions for deep breathing?

That is referring to something like diaphragmatic breathing. We want to help our patients differentiate between shallow breathing and that deeper breathing kind of using the diaphragm.   4, 7, 8 breathing is another one that I recommend quite a bit. That's inhaling through your nose for four seconds, holding for seven seconds and then exhaling through your mouth for eight seconds. That can be a really great way to calm someone's nerves and help them reset.

I have been reprimanded by my manager for discussing food choices. Any suggestions?

I’m sorry to hear that. We always hear things like that in some places, “That's not your job.That's somebody else's job.” But hopefully, you're getting some information in this course that providing some education is within our scope and is absolutely  preventative. If we're doing it related to swallowing, it's 100% something that we should be doing. But in terms of looking at brain health, now you can say that it's important for me to talk to my patients about ways they can eat better because that's going to help them with their overall health and ultimately their cognitive health. So, I would push back a little bit on that. Maybe once you educate that person there will be a little more understanding.

Have you found that Medicare or other insurance companies will pay for speech-language pathology for subjective cognitive decline only if the client does not have another SLP diagnosis and doesn't demonstrate cognitive deficits? Have you seen any pushback in terms of getting those covered?

No, I haven't in the home health world. But I don't know if you are working in outpatient clinic or private clinic. If you’re working with a patient who has a definite diagnosis, you can start to infuse all these other things into a brain health program. But insurance companies are definitely eyeballing the ICD codes and that is going to be a factor. But I haven't seen it in the home health world.

If you are looking for a guide for how we started our group at KSU, feel free to email me. I'm happy to provide you with some resources.

References

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Alzheimer's Association (2021) 10 Ways to Love Your Brain. Accessed at https://www.alz.org/help-support/brain_health/10_ways_to_love_your_brain

American Association of Retired Persons (2021). What is Staying Sharp? Accessed at https://stayingsharp.aarp.org/about/brain-health/what-is-staying-sharp/

American Heart Association (2021) Brain Health; Accessed at https://www.heart.org/en/health-topics/brain-health

American Speech-Language and Hearing Association (1988) Position Statement: Prevention of Communication Disorders; Accessed at https://www.asha.org/policy/PS1988-00228/

American Speech-Language and Hearing Association (2016) Scope of Practice. Accessed at https://www.asha.org/policy/sp2016-00343/

Barnes, DE, Yaffe K, Belfor N, Jagust WJ, DeCarli, C, Reed, BR, & Kramer, JH. (2009) Computer-based cognitive training for mild cognitive impairment: results from a pilot randomized, controlled trial. Alzheimer Disease & Associated Disorders 23: 205-2010.

Belleville S, Clément F, Mellah S, Gilbert B, Fontaine F, Gauthier S. (2011). Training-related brain plasticity in subjects at risk of developing Alzheimer's disease. Brain. Jun;134(Pt 6):1623-34. doi: 10.1093/brain/awr037. Epub 2011 Mar 22. PMID: 21427462.

British Medical Journal (2020) What is Brain Health and Why is it Important? Accessed at https://www.bmj.com/content/371/bmj.m3683

Center for Brain Health (2021). What is Brain Health? Accessed at https://brainhealth.utdallas.edu/what-is-brain-health/

Centers for Disease Control and Prevention (2021) Chronic Diseases and Cognitive Decline. Accessed at https://www.cdc.gov/aging/publications/chronic-diseases-brief.html

Centers for Disease Control and Prevention (2021) Current Cigarette Smoking Among Adults in the United States. Accessed at https://www.cdc.gov/tobacco/data_statistics/fact_sheets/adult_data/cig_smoking/index.htm#:~:text=In 2019, nearly 14 of,with a smoking-related disease.

Centers for Disease Control and Prevention (2021). Depression is not a normal part of growing older. Accessed at https://www.cdc.gov/aging/depression/index.html  

Centers for Disease Control and Prevention (2020). Healthy Brain Initiative. Accessed at https://www.cdc.gov/aging/healthybrain/roadmap.htm 

Center for Health Statistics (2020) Prevalence of Obesity and Severe Obesity Among Adults; United States. Accessed at https://www.cdc.gov/nchs/products/databriefs/db360.htm 

Cleveland Clinic (2020) Six Pillars of Brain Health. Accessed at https://healthybrains.org/pillars/

Global Council on Brain Health (2021). Global Council on Brain Health. Accessed at https://www.aarp.org/health/brain-health/global-council-on-brain-health/ 

Barnes, DE, Yaffe K, Belfor N, Jagust WJ, DeCarli, C, Reed, BR, & Kramer, JH. (2009) Computer-based cognitive training for mild cognitive impairment: results from a pilot randomized, controlled trial. Alzheimer Disease & Associated Disorders 23: 205-2010.

Li, Huijie, Juan Li, Nanxin Li, Bing Li, Wang, P. & Zhou T. (2011). Cognitive intervention for persons with mild cognitive impairment: a meta-analysis. Ageing Research Reviews 10: 285-296.

Londos, E, K Boschian, A Lindén, C Persson, L Minthon, & J Lexell (2008). Effects of a goal-oriented rehabilitation program in mild cognitive impairment: A pilot study. American Journal of Alzheimer's Disease and Other Dementias 23.2: 177-183.

National Institute on Aging (2021) Cognitive Health and Older Adults; Accessed at https://www.nia.nih.gov/health/cognitive-health-and-older-adults

Tennstedt, S. L., & Unverzagt, F. W. (2013). The ACTIVE study: study overview and major findings. Journal of aging and health, 25(8 Suppl), 3S–20S. https://doi.org/10.1177/0898264313518133

Turner, R.S., Reynolds, B., Johnson, K., Chadwick, M., Bassett, M., & the Memory Disorders Program. A Four-Pillar Program to Preserve Brain Health. Accessed at https://memory.georgetown.edu/news/a-four-pillar-program-to-preserve-brain-health /

World Health Organization (2018)) Brain Health. Accessed at https://www.who.int/health-topics/brain-health#tab=tab_1  

World Health Organization (2001) International Classification of Functioning, Disability, and Health. Accessed at https://www.who.int/standards/classifications/international-classification-of-functioning-disability-and-health 

 

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