Editor’s Note: This text-based course is a transcript of the webinar, Forget Me Not...Evaluation and Treatment of the Patient with Dementia; Part 3: Evidence-based Treatments, presented by Amber Heape, MCD, SLP-CDP.
By the end of this course, you should be able to:
- Describe evidence-based treatment approaches for cognitive therapy
- Describe how to analyze appropriate therapy approaches by the level of patient impairment
- Explain how to compose daily documentation that supports the skilled services provided
Why Does it Matter?
The big question is, “Why does it matter?” What research is out there that is showing treatment to be effective? Why do we even bother? Well, 10 to 15 years ago when I started in this profession there was not much research available on cognitive linguistic therapy, especially for patients with dementia. But as we have discussed in prior courses, the population is aging and we do not want to place excess disability on our patients.
We, as SLPs, CNAs, nursing staff and even families can actually place excess disability on patients or residents by doing too much for them when they could do parts of tasks or entire tasks themselves. It may take a little longer, it may require more processing or cuing, but we do not want to take away our aging patients’ independence when it is not necessary.
Sometimes in skilled nursing, assisted living, or in homes with the aging, staff or family members provide maximum assistance thinking that it will save time or be easier instead of allowing the resident to do as much as he or she can. This actually increases the caregiver burden unnecessarily.
Time is of the essence, and if we are doing too much for a patient when we don’t necessarily have to that takes time away from completing assigned duties, providing care to patients, completing documentation and educating other staff members.
With this idea of excess disability, the focus should not be on disability but ability, not what we do for the patient, but what we can do with them and not providing too much care, but providing age-level appropriate challenges for the patient to be successful.
Building a Cognitive Therapy Program
Building a cognitive therapy program is not something that happens overnight. I have started cognitive therapy programs in two different facilities as the treating SLP, and now I work with 30 nursing homes, skilled nursing and post-acute care facilities to build and strengthen their cognitive programs as well.
The first step is having a desire to provide this type of program to change the quality of life for the aging, especially the aging with dementia. It starts with you being the patient’s advocate, not just going along with the status quo because that is how it has always been done. Next, you need to find a core team, whether that is the PT, OT, your department manager, nursing, a physician, and social worker. Talk to the people who will be really interacting with the patient and bring those key persons into your core group. Explain why you want to start this type of program and what it entails. Then build the team through teamwork and education. Make it a functional therapy program that could eventually be seamlessly integrated into your building.
For an effective program to last, it will take more than just an SLP. It will take other therapy disciplines such as admissions, the social worker, restorative nursing as well as nurses and certified nursing assistants, activities personnel, dietary, housekeeping personnel, and your CMD or your Medicare billing staff.
3 Models of Service Delivery with Communicative Impaired Clients
There are three models of service delivery for cognitive-linguistic communication therapy. I want to preface this by saying you will hear me say ‘cognitive therapy,’ but cognition and language are so intertwined in so many different aspects that I should take the time to say cognitive-linguistic therapy or cognitive-communication therapy. If I say ‘cognitive therapy,’ know that I am referring to aspects of cognition as well as aspects of language.
The first service delivery model is the medical model which is focused on the actual impairment. The physician determines whether those services will be provided. Most of the time this is used in acute care hospital settings. The clinician only has a few days to do what they need to do in many situations.
The second is a social model which really focuses on a society that is not inclusive of people with disabilities. It focuses on a disabling society. The focus of the intervention is on the interaction between the person and the society and the reduction of those barriers. The patient or the client actually determines what services are provided. This model is typically seen in residential or community settings.
The model that we utilize as therapists is a rehabilitation or rehabilitative model. The focus should be on the person’s inability to function in everyday activities or activities of daily living. The focus of intervention in a rehabilitative model is on the person who has the disability and how they are going to improve their function in their ADLs. It is more of a collaborative approach because the professional and the patient work together to determine what services are provided.
This model is typically used in rehabilitation units, post-acute care centers, skilled nursing facilities that also provide step down units (a.k.a. swing bed units) or rehab with patients who have had hospitalizations. In order to have an effective rehabilitation model we need to know what the patient’s prior level of function (PLOF) was. Was the patient able to communicate appropriately with the caregivers? Was the patient able to handle their own finances or their own medication? What was the patient’s diet like prior?