Multidisciplinary Management of Disorders of Communication ...

Multidisciplinary Management of Disorders of Communication, Cognition, and Swallowing

in Individuals with DementiaPresented by:

Rinki Varindani Desai, MS, CCC-SLP, CBIS, CDPSarah Faucette, AuD, PhD, CCC-A, F-AAA

2021 Fall Institute at Ole MissOctober 21, 2021

Rinki Varindani Desai, MS,CCC-SLP, CBIS, CDP

Rinki is a medical speech-language pathologist, certified brain injury specialist and certified dementia practitioner; specializing in the assessment and treatment of swallowing disorders in adults. She is currently the adult outpatient lead and a clinical instructor in the Department of Otolaryngology - Head Neck Surgery at the University of Mississippi Medical Center in Jackson. She serves as Associate Coordinator of ASHA’s Swallowing and Swallowing Disorders Special Interest Group (SIG 13), Co-Chair of the Dysphagia Research Society's COVID-19 Task Force and Chair of the MSHA Membership Committee. She is the co-founder of the Swallowing Training and Education Portal, founder of the Medical SLP Forum and co-creator of the Dysphagia Therapy mobile app. A recipient of multiple ASHA ACE awards, Rinki was one among 30 clinicians in the world selected for ASHA’s Leadership Development Program in 2017 and ASHA’s Faculty Development Instituteprogram in 2019. After receiving her B.S. in Audiology and Speech-Language Pathology in 2009 from AYJNISHD in Mumbai, she earned her M.S. in Communication Disorders from the University of Texas at Dallas in 2011. She has practiced for over a decade in acute, sub-acute, outpatient, and long-term care medical settings. Rinki has presented nationally and internationally, as well as published on topics related to adult dysphagia. She enjoys reading, writing, traveling, and doing what she can to help advance the profession by paying it forward.

[email protected]

Sarah Faucette, AuD, PhD, CCC-A, F-AAA

Dr. Sarah Faucette is as an assistant professor of audiology in the Department of Otolaryngology- Head and Neck Surgery at the University of Mississippi Medical Center. She is dual-appointed with the MIND Center, where she is the lead clinical research audiologist for the Aging and Cognitive Health Evaluation in Elders (ACHIEVE) trial and site principal investigator of the Hearing Intervention Follow-up Study (ACHIEVE-HIFU). She earned both her Doctorate of Philosophy in Communication Sciences and Disorders and her Doctorate of Audiology degrees from East Carolina University in North Carolina. Faucette’s professional interests include hearing loss in the aging population, amplification, and tinnitus.

[email protected]

What is Dementia?• A terminal, progressive, chronic illness resulting from biological changes in the brain

• A “collection of symptoms” related to cognitive decline. Can include cognitive, behavioral, communicative & psychological symptoms

• 2nd most commonly reported symptom in geriatrics

• Alzheimer’s Disease is the most common type

• Note: Some causes of cognitive decline are reversible and not truly dementia

Dementia - A Public Health Priority

Dementia Types and Symptoms

Multidisciplinary Dementia Management

Early diagnosis by a multidisciplinary team improves outcomes and quality of life

Goals of care:o Early diagnosis

o Detecting and treating / compensating for communication, swallowing and cognitive problems

o Providing information and long-term support to caregivers

o Optimizing health, independence, safety, well-being

Medical Speech-Language Pathologists

• Minimum of a Master’s Degree + Clinical Fellowship

• Specialize in evaluation and treatment of speech, language, cognitive-communication, voice and swallowing

• Usually specialize in a certain population, setting or disorders – often cross trained in the medical setting

• Work in multiple settings, treat patients across the lifespan

• Serve as an integral member of many interdisciplinary teams – particularly related to dementia care

SPEECH, LANGUAGE AND COGNITIVE IMPAIRMENTS IN INDIVIDUALS WITH DEMENTIA

Klimova, B., & Semradova, I. (2016). Cognitive decline in dementia with special focus on language impairments.European Proceedings of Social and Behavioural Sciences Cyprus: Nicosia, 86-90.

Key Language Impairments in Early Stages of Dementia

Impact of Communication Impairments

● Avoiding social situations● Increase in problem behaviors● Increased stress on the

caregivers ● Compromised safety

and well-being● Loss of independence

● Word finding difficulties● Difficulty telling a cohesive

story or communicating wants and needs

● Trouble understanding lengthy and complex information

● Difficulty participating in conversations

may lead to..

Cognitive – Communication Deficits

Seen commonly in older adults, usually associated with stroke, brain injury, neurodegenerative diseases etc.

Often irreversible in older adults with dementia

Deficits include: attention, orientation, memory, executive function, judgment, problem solving, reasoning, sequencing, thought organization

Delirium v/s depression v/s disorder – need to differentially diagnose accurately

• Who?oAny MD can diagnose DementiaoBest practice: Referral to Neurology or PsychiatryoReferral to a Neuropsychologist may follow

• How?oMedical/physical/mental status examoNeurological ExamoBrain imaging (usually an MRI brain)oGenetic testing (not routine)

• FOCUS: R/O other contributing factors

• REFERRALS: To different disciplines (RD, SLP, OT, PT, RT etc.)

Diagnosing the Big D

Objective Cognitive Assessments

MOCA SLUMS

Overview of Assessment in Individuals with Dementia

Assessment typically includes:

• Relevant case history, including medical status, education, occupation, and socioeconomic, cultural, and linguistic background;

• Review of auditory, visual, motor, cognitive, and emotional function;• Co-morbid deficits that impact communication / cognition • Patient and family reports of goals, preferences, as well as concerns;• Standardized and nonstandardized tests selected

with consideration for ecological and cultural validity;• Contextual factors that serve as barriers / facilitators • Follow-up services / referrals to optimize cognitive-communication

function, ensure appropriate intervention and offer support

• Early diagnosis is key to avoid complications and slow down progression

• A complete clinical evaluation should help you identify underlying impairments and need for SLP services

• Ask these three critical questions: • Can the patient consume adequate food, liquid, medication by mouth?• Is the patient safe in their current environment? • Can the patient communicate basic wants and needs?

Overview of Assessment

Objective Cognitive Assessments

MOCA SLUMS

Additional Assessments for Communication & Cognition• Arizona Battery for Communication Disorders of Dementia (ABCD)

• Brief Cognitive Assessment Tool (BCAT)

• CLQT (Cognitive-Linguistic Quick Test)

• BDAE (Boston Diagnostic Aphasia Exam w/ Boston Naming Test)

• WAB (Western Aphasia Battery)

• FDA (Frenchay Dysarthria Assessment)

• ABA (Apraxia Battery for Adults)

• ALFA (Assessment of Language-Related Functional Activities)

• FLCI (Functional Linguistic Communication Inventory)

• RIPA G-2 (Ross Information Processing Assessment—Geriatric, Second Edition)

Dementia Staging: Global Deterioration Scale

Developed by Dr. Barry Reisberg

Overview of the stages of cognitive function for those suffering from a primary degenerative dementia

7 stages:(No cognitive decline – Severe Dementia)Stages 1-3 are pre-dementia stagesStages 4-7 are the dementia stages

Beginning in stage 5, an individual can no longer survive without assistance.

Dementia: Functional Assessment• Go beyond traditional assessments and conduct more functional measures to

determine the individual’s strengths and weaknesses

• Incorporate personal goals leading to greater treatment success

• Goals must be SMART

• Prior level of functioning should warrant goal being addressed

• Need for each goal should be well-documented

• Be aware of test length and level of difficulty

• ASSESSMENT IN PWD IS AN ONGOING PROCESS

• When designing a care plan for maximizing function, refer to the following (Bayles & Tomoeda):o Strengthen the processes that have the potential to improveo Reduce demands on impaired cognitive systemso Increase reliance on spared cognitive systemso Provide stimuli that evoke positive memory, action, and emotion

• SLPs have an ethical responsibility to provide appropriate services that will benefit the individual and maximize cognitive-communication functioning at all stages of the disease process.

Dementia: Treatment Guidelines

Evidence-Based Interventions

Direct Interventions:• Sensory stimulation • Spaced Retrieval Training • Errorless learning methods • Montessori-based programming• Reminiscence therapy• Validation therapy

Indirect Interventions:• Caregiver education and training• Environmental modifications• Use of external aids and supports

Top Treatment Takeaways and Considerations

• Many factors to consider during assessment, developing care plan and providing treatment

• Both rehabilitative and facilitative services are appropriate for adults with dementia – to improve safety, function, and quality of life across all stages of severity.

• Achieving buy-in from the family / caregivers is critical in the carryover of treatment goals.

• Make yourself a common part of the interdisciplinary team - to keep updated on patient progress & to explain role, goals andtreatment to staff.

• Documentation should clearly and objectively specify how our skilled therapy services are helping to improve function in the specific domain that was assessed.

• Treatment must be individualized and patient-specific. One size does not fit all!

SWALLOWING IMPAIRMENTS (DYSPHAGIA)

What is DYSPHAGIA?

The word dysphagia is derived from the Greek words phagia(to eat) and dys (with difficulty).

It specifically refers to the sensation of food being hindered in its normal passage from the mouth to the stomach.

Dysphagia = any impairment in normal swallow function

Signs and Symptoms of Dysphagia

• Difficulty chewing • Pocketing (food remaining in the oral cavities)• Nasal regurgitation of food / liquids• Frequent throat clearing at meals• Coughing / choking at meals • Wet / gurgly voice quality• Multiple swallows per bolus • Globus sensation • Food “stuck” / “lump” in throat • Undesired weight loss• Fatigue when eating / drinking• Inability to manage secretions • Effortful chewing / swallowing

• Prevalence of dysphagia in individuals with dementia is between 13% and 57% (Alagiakrishnan, Bhanji, and Kurian, 2013)

• 45% of institutionalized elderly present with the dual diagnosis (Easterling and Robbins, 2008)

• Higher incidence of oropharyngeal swallowing abnormalities, including silent aspiration, more prevalent in patients with Alzheimer's disease than in normal elderly individuals (Horner et al, 1994)

• Prevalence of dysphagia in severe Alzheimer’s disease has been estimated between 84% to 93% (Affoo, Foley et al. 2013)

• Different clinical presentations of dementia will result in different swallowing or feeding impairments (Alagiakrishnan et al, 2013)

Dysphagia in Persons with Dementia (PWD)

Alagiakrishnan, K., Bhanji, R. A., & Kurian, M. (2013). Evaluation and management of oropharyngeal dysphagia in different types of dementia: a systematic review. Archives of gerontology and geriatrics, 56(1), 1-9.

Including “typical” dysphagia symptoms, PWD may also develop:

o Food agnosia resulting in difficulty distinguishing food from non-food items (Wasson, 2001)

o Perceptual and spatial deficits resulting in difficulties recognizing food and utensils (Brouwers, 1984)

o Apraxia resulting in difficulty performing voluntary actions (Benke, 1993) (i.e., opening the mouth to a spoon or moving food from the front to the back of the mouth)

o Work with OT and PT colleagues to help manage these

Dysphagia in PWD

Dysphagia Management in PWD

Screen all patients at risk of dysphagia

Clinical (bedside) swallowing assessment

No Problem Problem

Instrumental swallowing assessment if indicated

(VFSS or FEES)Determine diet

texture + referrals

Monitor over time

Rehabilitative or compensatory intervention

Dysphagia Screening

• Who: all patients in recognized risk groups• Why: reduces risks of aspiration pneumonia, mortality

and need for enteral feeding (Martino et al., 2005)

• When: before initiating oral intake• How: informal vs. formal

• Formal is better – lower incidence of pneumonia (2.4% v. 5.4%) (Hinchey et al., 2005)

• Formal screening has been evaluated in acute stroke population

• Other disorder groups may require different approaches.

Dysphagia Screening

3 oz water swallow test (Suiter, 2008)

Only validated tool for PWD

“Drink all the water until the cup is empty”Fail if:

• Coughing or choking• Wet or hoarse voice quality• Inability to complete task

Either during or within 1 min of completion

Another Screening Option?

Mealtime durations over ~40 minutes are significantly associated with suspected dysphagia in LTC (Namasivayam-MacDonald, 2018)

Implications:• If resident is consistently taking >40 minutes to eat, then a

clinical swallow evaluation is warranted.• Since medical status changes often, screening should be

performed at quarterly check-ups.• Any failed screening should lead to a CSE

• Detailed Chart review• Patient / caregiver interview • Oral-facial and Sensory-Motor (Cranial Nerve) exam• Speech-Language and Cognitive Status• Ability to follow directions • Assessment of vocal quality and respiratory stability • PO trials of various consistencies • Helps form a hypothesis of the problem • Patient's perception of function, severity, change

in functional status and quality of life• Findings help determine management and

need for instrumentals / referrals and develop POC

THE CLINICAL SWALLOW EVALUATION (CSE)

Instrumental Swallowing Assessments

VFSS: Videofluoroscopic Swallow Study• MBSS (Modified Barium Swallow Study)• Dynamic visualization of swallow / bolus flow• Allows for visualization of all swallow stages

FEES: Fiberoptic Endoscopic Evaluation of Swallowing • May be difficult with a patient with severe cog

impairment and/or Parkinsonian tremors• Can only visualize pharyngeal phase• Can see anatomical structures, mucosa,

secretions and secretion management

VFSS VIDEO EXAMPLES:

Normal Swallow, Normal Aging Swallow, Aspiration in Person with Dementia

37

Enables the SLP to:

• Visualize the structures of the upper aerodigestive tract

• Assess the physiology of swallow structures

• Determine presence, cause and severity of dysphagia

• Identify penetration / aspiration risk

• Determine with specificity the relative safety and efficiency of various bolus consistencies and volumes.

• Assess therapeutic strategies

Instrumental Swallowing Assessments

Compensatory Strategies and

Diet Modification

Caregiver Training and Education

Alternate Nutrition and

HydrationSwallow

Rehabilitation

Sensory Treatments

Dysphagia Intervention Options in PWD

The goal of dysphagia therapy in PWD is to optimize the safety and efficiency of the oropharyngeal swallow, help reduce feeding related

behavior issues, to maintain adequate nutrition and hydration, to improve oral hygiene and to maximize quality of life.

• GOOD ORAL HYGIENE• Consistent environment in the dining room for mealtime/eating• Encouraging smaller meals throughout the day • Consulting with RD about nutritional supplements • Encouraging self-feeding• Making food visually appealing• Reducing clutter and distractions• Providing finger foods • Providing food choices• Focus on patient preferences • CAREGIVER TRAINING

(Amella, 2002; Brush & Calkins, 2012; Chang & Roberts, 2008).

Optimizing Nutrition and Hydration in PWD

Dysphagia Management in PWD

Swallow safety

Quality of life

“Is the burden of treatment outweighing the benefit?” (Ferrell & Coyle, 2010; Palecek & Teno, 2010)

Painter, V., Le Couteur, D. G., et al. (2017). Clinical Interventions in Aging, 12, 1193-1203.

• Are we right about our diet recommendations? o Among nursing home residents, 91% of patients placed on modified diets were on overly restrictive diets. o Only 5% of identified to be on an appropriate diet level matching their swallow ability and 4% of patients

placed on diets above their clinically measured swallow ability. (Groher, 1995)

• Although recommended to promote safe swallowing and reduce aspiration in patients with dysphagia, modified diets may result in reduced food intake and increase the risk of malnutrition / dehydration for PWD (Wright et al, 2008)

• Insufficient evidence found to suggest texture-modified food and fluids produce clinically significant beneficial effects on aspiration, pneumonia, nutrition and hydration, morbidity or mortality for individuals with dementia. (Painter et al., 2017)

Diet Modifications in PWD

Populations most commonly receiving ANH include the general category of dysphagia (64.1%), and patients with Stroke (65.1%) or Dementia (30%)

No data to suggest that tube feeding of patients with advanced dementia prevented Aspiration PNA or prolonged survival rates. (Finucane et al, 1999)

Little evidence that non-oral feeding improves nutritional status or increases life expectancy in advanced dementia

Various factors to consider in PEG placement

Alternate Nutrition and Hydration (ANH) in PWD

Role of the SLP in Palliative Care

SLPs play important role in palliative and end-of-life care

Roles of the SLP: Assistance, Advocacy, Agent of Change

Carefully consider potential harm of dysphagia interventions, such as modified diets and FT placements

Paradigm shift from rehabilitation and compensation, towards palliation and patient-centered care

Caregiver training, support and education

Care, C., Doors, B. C., Book, S., Toolkit, C. G. A., Thames, B. G. S. N. E., Thames, N. W., ... S. A. S. Dysphagia Management for Older People Towards the End of Life. - http://www.bgs.org.uk/

Person-Centered Multidisciplinary Team Approach

• Patient, family, and healthcare professionals are a “unit of care”

• TEAM GOALS: Minimize symptoms and maximize patient’s autonomy

• Ensure that the patients’ best interests remain at the core of the management plan as part of current and emerging goals of care.

• A coordinated approach, particularly towards the end of life is essential for patients with dementia and other chronic, progressive conditions, to ensure consistent transfer of care between acute and community settings.

So – if anyone asks “How can an SLP help?”• Education: Provide patient and family education on the impacts of Dementia diagnosis

on cognition and language, and what can be done to maintain the person’s well-being

• Identification and Compensations: Optimize retained abilities and teach the use of compensatory strategies that will improve the patient’s cognitive/communicative functionas well as establish patterns that will be helpful in the future.

• Therapeutic Intervention: Therapy provided on an ongoing basis as the disease progresses - to develop and modify communication strategies and aids as needed

• Caregiver Support: Training the care partner in effective communication and feeding strategies and aids, to decrease problem behaviors and maximize QOL

We cannot change the disease but….

We can change how we respond to it.

We can change how we think about it.

We can take time each day to focus onwhat remains, strengths, positive momentsof connection, or even laughter.

With help, we can maximize a person’s abilities to help them remain independent, connected to themselves and others, and hopeful.

“In the end it's not the years in your life that count; it's the life in your years. ” — Abraham Lincoln

HEARING LOSS AND COGNITIVE DECLINE

What do we know?

Prevalence of Age Related Hearing Loss in the US, 2001-2008

Lin et al., Arch Int Med. 2011

Lancet Commission on Dementia Prevention, Intervention, and Care

Modifiable Risk Factors for Dementia:

Hearing loss

Less education

Smoking

Depression

Social isolation

TBI

Hearing loss in mid and late life identified with the greatest population attributable fraction of risk (8%)

G. Livingston et al., Lancet, 2020

Hearing Loss and Cognition

• NHANES: National Health & Nutritional Examination Surveyo Cross-sectional, representative sample of U.S. population

• BLSA: Baltimore Longitudinal Study of Agingo Ongoing prospective study of >1000 older adults since 1958

• HealthABC: Health, Aging, & Body Composition Studyo Prospective, population-based study of ~3000 adults 70 years and older

• ARIC: Atherosclerosis Risk in Communities Studyo Prospective, population-based study of ~16,000 adults followed since 1987

Lin et al., JAMA Int Med 2013

With hearing loss: • Poorer cognitive

function• Faster rate of

cognitive decline

Hearing Loss and Cognition

Hearing loss

Increased Cognitive

Load

Reduced Social

Engagement

Brain Structure/Function

CognitiveDecline

Brain Structure and Function

• HL is associated with reduced cortical volumes in the primary auditory cortex (Husain et al.,Brain Research, 2010; Peelle et al, J. Neuroscience, 2011; Eckert et al., JARO, 2012)

• Variation in central auditory white matter tract integrity (Chang et al., Neuroreport, 2004; Lin et al., J. Magn Reson Imaging, 2008)

• Faster rates of right temporal lobe atrophy in individuals with hearing loss (Lin et al., Neuroimage, 2014)

Reduced Social Engagement“Blindness separates us from things but deafness separates us from people.“ Helen Keller

• Significant correlation between hearing loss and Objective and Subjective Social Isolation Scale scores (Weinstein & Ventry, JSHR, 1982)

• Older adults with hearing loss are more likely to feel lonely or remote and feelleft out, even in a group (Strawbridge, et al., Gerontologist, 2000)

Increased Cognitive Load

“We hear with our ears, but we listen with our brain”

Capacity Model of Attention (Kahneman, Attention & Effort)oAssumes there is a limit to the capacity to perform mental work

Hearing loss increases the difficulty of listening; increasing the effort it takes to do so, and reducing the effort available to do other tasks, such as remember and respond in conversations.

HEARING LOSS AND COGNITIVE DECLINE

Prevention? And Treatment Options

Hearing Loss Intervention Could…

• Reduce cognitive load of processing degraded sound

• Improve social engagement

• Provide increased brain stimulation Intervention

Increased Cognitive

Load

Reduced Social

Engagement

Brain Structure/Function

CognitiveDecline

ACHIEVE Trial Three-year randomized clinical trial at 4 sites across the country

Investigating two different treatments that may promote healthy aging and cognitive health in older adults

Hearing intervention hearing needs assessment fitting of hearing devices education/counseling

Successful Aging intervention individual sessions with a health

educator covering healthy aging topics

ACHIEVE Trial

OutcomesoNeurocognitive battery- memory, executive function, etc…oAdjudicated dementia/MCI diagnoses, depression,

communicative & social function, physical functioning, accelerometry, falls, hospitalizations, HHIE, hearing aid data logging, MRI

HEARING LOSS AND COGNITIVE DECLINE

Testing and Treating

Hearing Testing - Patients with Dementia (PWD)

• Identify functional abilities• Consider anxiety/

paranoia

• Be mindful of dignity and respectoGive patients an “out”

Sperling, R.A., et al (2011)

Hearing Testing - PWD (cont.)

• Reinstruct and redirect as needed

• Narrate procedures- reduces anxietyo “I’m walking behind you to pick up my equipment”o “Ok, now I’m going to put these headphones in your ears”

• Order procedures by priority

Treating Hearing Loss in PWD

Consider the continuum of disease as well as caregiver support

Hearing Loss intervention in (PWD)

Worse hearing is associated with increased neuropsychiatric symptoms (NPS; delusions, hallucinations, agitation, depression, anxiety, etc…) in adults with cognitive impairments

Hearing aid users experience reduced NPS

Effective communication may help manage NPS

Kim et al., 2021

Managing Communication Impairments

DevicesoHearing aidsoPSAPSoPocket Talkers

Communication Strategieso Speak slowlyoDon’t cover

your mouth o Turn on the lightsoReduce distractions/noiseoDon’t just repeat- rephrase

The MIND Center

The MIND Center is a national leader in Alzheimer’s research and clinical care backed by UMMC

Started in 2010 and led by Dr. Tom Mosley, a nationally recognized leader in brain aging

The MIND Center uses pioneering research, state-of-the-art brain imaging, and powerful genetic technologies to crack the code of Alzheimer’s disease and other dementias

The MIND Center Clinic offers diagnosis and treatment for patients with memory loss and cognitive impairment.

MIND Center Research

ACHIEVE Study

ARIC Study

Study of Aging

MIND Center Clinic Experienced multi-disciplinary team (geriatricians, neurologist,

consulting neuropsychologists and psychiatrists, nurse practitioner, social worker, RN care coordinators and patient schedulers)

Patient and family visit with social worker or RN care coordinator for guidance and support Community resources Financial information Working through behavioral concerns

Collaboration with primary care doctor

Ongoing visits (every 3 – 6 months) to monitor disease and medications and support patient and family/caregiver

MIND Matters

Free community education series focused on Alzheimer’s disease and other dementias

Previous topics: Financial Readiness as You Age The Health Effects of Sleep Apnea Hearing Loss and Cognitive Decline Music and Memory

Register for future talks: Email: [email protected] Telephone: 601.815.4237

THANK YOU FOR LISTENING! QUESTIONS?