Principles of Intervention and Treatment

1
Principles of Intervention and Treatment
2
Treatment Planning

• Given our current knowledge about mechanisms of
  neurological recovery and language processing,
  three clinical principles should guide treatment
• Emphasize the positive. Use personal,
  communicative, and linguistic strengths in
  goal-setting and treatment methods.
• Focus on functional outcome. Adapt treatment
  content to personal interests, background, and
  goals.
• Respond to patient and family feedback. Change
  treatment goals and methods through continual
  reappraisal of patient responsiveness.

3
Treatment Planning

• Recommend communication treatment for all
  patients with aphasia, at least on a trial basis.
  
• The rationale underlying aphasia treatment
  oriented toward an individuals strengths and a
  positive recovery outlook is not designed to
  foster denial but to inspire the person to muster
  all available personal resources to fight the
  hard battle of aphasia rehabilitation that lies
  ahead.
• Base treatment on mutual goals set by the patient
  and his/her family, as well as by the functional
  outcome needs of the individual and the family
  nucleus.

4
Treatment Planning

• For those with right hemisphere syndrome,
  recommend treatment to improve communication,
  cognitive, and perceptual functioning.
• Because recent evidence suggests that language
  processing in the brain involves several
  processing language in parallel rather than in
  sequence, a more effective method of targeting
  language and communication goals would be to
  stress multiple language modalities through
  functional tasks instead of traditional
  modality-specific tasks, that are stressed in
  sequence.

5
Selecting Treatment Goals

• After completing an initial diagnostic
  assessment, the clinician compiles a list of
  communication or language skills that testing
  reveals have been impaired, as well as those that
  testing, informal probes and family input
  indicate the individual has maintained.
• Plot the patients relative strengths and
  weaknesses on a graphic modular aphasia profile.

6
Selecting Treatment Goals

• Using the modular profile, share the information
  with the patient and family and use the map to
  target treatment goals and select treatment
  stimuli.
• It is generally best to target a midrange ability
  level for treatment goals.

7
Selecting Treatment Goals

• By setting communication goals and using
  procedures that incorporate intact abilities, the
  aphasic person can begin the treatment process by
  succeeding.
• Although aphasiologists have long stressed the
  importance of using functional assessment and
  treatment strategies to maximize the aphasic
  individuals performance in real-life situation,
  the vast majority of SLPs still rely heavily on
  standard published workbooks and programmed
  materials.
• Functional treatment approaches need not take
  excessive preparation time if family members are
  included in the treatment team and are encouraged
  to select and adapt materials that respect the
  patients vocational or avocational interests.

8
Developing Functional Outcome Goals

• When developing functional outcome goals and
  treatment stimuli to reach these goals, three
  issues need to be considered
• Active intervention in the environment.
• Gainful employment or avocational interests.
• Social contact/interactive stimulation.
• Before initiating a treatment program, the
  clinician should identify the interactive
  routines and needs of the family, including
  family dinners, social gatherings with friends,
  religious celebrations or weekly attendance at
  church or synagogue, and eating out.

9
Developing Functional Outcome Goals

• For many clients with aphasia, real events in
  family life make the best material for practice.
• Each interactive session should be planned in
  advance, determining who the participants will
  be, where the interaction will take place, and
  the goal.
• Events can be staged and then practiced through
  group sessions and trips, actual in-home
  treatment with family members present, and role
  playing.
• Examples of this kind of therapy would be
  planning a picnic with friends, discussing a
  family reunion with other family members,
  conversing with a spouse on a trip.

10
Developing Functional Activities

• Burns (1996) reported on a client who became
  concerned when he attended a gala banquet and had
  difficulty following the conversation at a large
  table.
• To prepare for the next similar event, his wife
  and two of her friends joined him to practice
  conversing across their dining room table.
• As he experienced difficulties, he and his wife
  tried to determine which aspects of the situation
  posed the greatest problems.
• They then worked together to find a solution.

11
Developing Functional Activities

• The client learned from the experience that he
  was very dependent on lip reading and eye contact
  to aid comprehension.
• Consequently, he learned to make a conscious
  effort to directly attend to each new speaker.
• After practicing this a few times at home, he
  attended the next event and found that his
  comprehension had improved markedly.

12
Developing Functional Activities

• Another good source of clinical material comes
  from the patients own vocational or avocational
  background.
• Not only are materials related to previous job or
  interests more motivating because of their
  familiarity, often they present a means for
  easily tapping into the individuals premorbid
  strengths and interests.
• As long as clinicians are careful to adapt the
  activities to the persons competence level,
  these types of activities provide incentive and
  optimism that at least some level of prestroke
  functioning can be reattained.

13
Developing Functional Activities

• Another case offered by Burns (1996) was W.A., a
  62-year-old female former secretary with a severe
  Brocas aphasia.
• She had been an avid bridge player before her
  stroke but all therapeutic attempts to rekindle
  this skill had been unsuccessful because her
  symbolic memory was too poor to remember previous
  hands played during a game.
• She was very upset that she could not again play
  bridge, but since card playing was important to
  her, her husband decided to try similar games.

14
Developing Functional Activities

• Soon, with a few adaptations, she was able to
  play hearts and canasta, and in time the two of
  them resumed card parties with friends.
• The person with aphasia is most often the best
  judge of whether techniques, procedures, and
  goals are appropriate and effective.
• When the client seems frustrated or progress
  seems minimal, the SLP should change treatment
  goals and methods and continually reappraise the
  patients responsiveness.

15
Developing Functional Activities

• Patient and family feedback are powerful sources
  of information and fresh ideas.
• So remember, to change goals when you, the
  client, or a family member discovers new areas of
  interest or need and
• Continually experiment with new methods for
  reaching long-term goals more quickly.

16
Treatment Guidelines for TBI

• A two-stage pattern of cognitive and
  communication recovery typically occurs following
  TBI.
• First the brain heals itself, and a certain
  amount of improved functioning occurs
  spontaneously.
• Dramatic changes in cognitive and physical
  functioning may occur during the early stages of
  recovery from TBI.
• During this period, many individuals do not have
  adequate attention and/or stamina to participate
  fully in the assessment or treatment process.

17
Treatment Guidelines for TBI

• During the initial recovery period, informal
  assessment should occur on a daily basis as part
  of intervention sessions.
• Later, when the individual has emerged from
  posttraumatic amnesia (PTA) and can participate
  actively in a variety of activities, the second
  stage of recovery begins and the SLP should
  perform a comprehensive evaluation of the
  functional impact of cognitive-communication
  impairments on a survivors life.

18
Treatment Guidelines for TBI

• At this time, persistent areas of impairment and
  their functional impact on an individuals
  participation in daily activities becomes
  evident.
• Periodic reevaluation may be necessary for an
  extended time period post-injuryoften for
  several years.
• Because of this differential pattern of recovery,
  rehabilitation professionals must provide two
  types of intervention.

19
Treatment Guidelines for TBI

• The first type of intervention facilitates
  restoration of basic cognitive and communication
  processes.
• The second type facilitates mastery,
  implementation, and generalization of
  compensatory and accommodation strategies.
• Cognitive-communicative rehabilitation (CCR)
  encompasses the assessment and treatment of
  underlying cognitive processes as they interact
  and are manifest in communication behavior at all
  levels of language at both levels of recovery.

20
History of Cognitive-Communicative Rehabilitation

• In the early period of program development for
  survivors of severe TBI, cognitive rehabilitation
  was understood by many practitioners as an
  enterprise that involved
• Hierarchical organization of cognitive processes
  and sub processes
• Creation of cognitive exercises that targeted
  specific aspects of cognition in a hierarchical
  manner and
• Delivery of cognitive exercises outside of the
  context of functional application (e.g.,
  cognitive retraining software).

21
Process-Specific Approach to Intervention

• The early developments in TBI rehabilitation were
  remarkably similar in theory and practice to
  unsuccessful 19th century attempts to cure mental
  retardation with hierarchically organized
  cognitive exercises.
• In the mid-20th century learning disabilities
  were addressed with similar decontextualized
  cognitive exercises.
• Out of these orientations grew the
  process-specific approach to intervention.

22
Process-Specific Approach to Intervention

• This hierarchical, process-specific approach to
  intervention directly targets cognitive processes
  that are judged to interfere with successful
  communication.
• Several published workbooks have been developed
  for use with a process-specific approach to
  target high-level cognitive skills.

23
Functional Approach to Intervention

• In the last decade, a functional approach to
  intervention has begun to emerge that recognizes
  the importance of improving cognitive processing
  within the context of meaningful academic,
  vocational, social and other daily activities.
• The functional approach emphasizes the concept of
  positive, supported, everyday routines of action
  and interaction with the goal of helping people
  with TBI acquire flexible and situationally
  successful routines of everyday life and apply
  appropriate scripts to guide successful thinking,
  remembering, problem solving, decision making,
  talking, and acting in social context.

24
Initial Stage of Recovery

• As a person emerges from a coma or state of
  minimal consciousness and progresses through the
  first three Rancho Levels, pervasive medical and
  cognitive problems mask language functioning.
• Systematic assessment of cognitive-communicative
  deficits is not possible at this time.
• Instead, small changes in responsiveness and
  awareness of people may be observed or measured
  with the Rappaport Coma/Near Coma Scale
  (Rappaport, Dougherty, Kelting, 1992).

25
Initial Stage of Recovery

• The Rappaport Coma/Near Coma Scale utilizes up to
  10 sensory stimuli and monitors for spontaneous
  vocalizations.
• A professional determines a score that
  corresponds to one of five levels describing the
  severity of a persons deficits in sensory,
  perceptual, and primitive responses.
• During this period of recovery, sensory
  stimulation is the usual course of treatment.
• Sensory stimulation is a program aimed at
  increasing the arousal, awareness, and
  responsiveness of slow-to-recover individuals.

26
Sensory Stimulation

• Multi-sensory stimulation occurs through several
  modalities (e.g., visual, auditory, tactile,
  gustatory, olfactory, and kinesthetic).
• Typically, several therapeutic areas participate
  in sensory stimulation programs, and family
  members/ friends should also play a role.
• Unfortunately, little research has been done to
  document the effectiveness of sensory stimulation
  programs.
• The research that does exist is open to
  criticism.

27
Sensory Stimulation

• Small sample sizes, variations across
  participants in time between injury and
  intervention, lack of control groups, selection
  biases, and methodological problems, especially
  differentiating treatment effects from
  spontaneous recovery have been criticized.
• However, a number of researchers have documented
  positive outcomes associated with sensory
  stimulation several months post-treatment.
• These positive outcomes include

28
Sensory Stimulation

• increased eye opening and body movements
• changes in pulse rate and heart rate and
• changes in EEG readings (Hall et al., 1992 Jones
  et al., 1994 Kater, 1989 Pfurtschuller, Schwarz
  List, 1986 Wilson, Powell, et al., 1991
  Wilson, Borck Powell, Thwaites, Elliot, 1996).

29
Posttraumatic Amnesia (PTA)

• When survivors of TBI progress from vegetative
  states to minimally responsive states, and again
  when they progress from being minimally
  responsive to displaying characteristics of PTA,
  substantial changes occur in treatment
  participation and orientation.
• During early stages of recovery, rehab
  professionals impose sensory stimulation on the
  survivor, who has a passive role.
• However, once a survivor begins responding to
  environmental stimuli, participation in treatment
  changes from passive to active.

30
Posttraumatic Amnesia (PTA)

• At this stage of rehabilitation, minimally
  responsive survivors should be presented with
  tasks that allow choice making via switch
  activation or natural communication (e.g., eye
  blink hand squeeze) to indicate a preference for
  one activity or item over another.
• The goal is to allow the survivor as much control
  over events as possible, to encourage
  communicative interaction with others, and to
  facilitate active participation in therapy.

31
Posttraumatic Amnesia (PTA)

• Once the survivor gains skills and consistency
  with choice-making, other kinds of cognitive
  intervention is possible.
• Cognitive treatment during PTA primarily focuses
  on improving attention, orientation, and memory.
• Professionals should expect survivors to vary
  considerably in their attending behavior based on
  a level of fatigue, changes in medication, and
  overall emotional and cognitive status.

32
Attention

• Paying attention to environmental events and
  stimuli is a fundamental underlying process of
  learning and memory.
• Three kinds of attention--sustained attention,
  focused attention, and divided attention--can be
  negatively affected by TBI.
• Sustained attention refers to the act of
  maintaining focus on a given task for a
  protracted period of time.
• Sustained attention tasks for a survivor of TBI
  might involve looking at family pictures,
  listening to music, or answering biographical
  questions.

33
Attention

• Focused attention involves attending to one task
  despite the presence of distracting stimuli in
  the immediate environment.
• The same kinds of activities utilized with
  sustained attention can be performed but in
  increasingly more complex and distracting
  environments.
• Divided attention requires a shift between two or
  more activities occurring simultaneously.

34
Attention

• When working on divided attention, a therapist
  might request a that a survivor of TBI
  alternately read sentences on one piece of paper
  and write key words on another.
• As attention improves, additional environmental
  distractors can be added so that therapy
  situations becomes less sterile and more like
  vocational and academic settings.
• However, inconsistent attention is a hallmark of
  TBI, especially when a survivor is experiencing
  agitation.

35
Orientation

• As people progress through PTA, they become
  increasingly aware of their environment and those
  around them.
• Appropriate environmental cues can be utilized by
  family members and staff to help the survivor.
• These include calendars, signs, stating the
  facility name and location, labels providing the
  names of specific rooms within the facility,
  written schedules of daily activities, maps of
  the facility, directional cues for navigating
  from one place to another, and simple memory logs
  of daily events.

36
Memory

• The predominant memory impairments associated
  with PTA are retrograde and anterograde amnesia.
• Retrograde amnesia refers to memory loss
  extending backward in time from the moment of
  injury.
• For many survivors, the time period of retrograde
  amnesia is initially quite large, spanning
  several weeks, months, or even years.
• With recovery, this time period often decreases
  to a few days or hours.

37
Memory

• Anterograde amnesia refers to memory loss of
  events occurring after the time of trauma.
• This includes the period of the coma, vegetative
  state, and minimal responsiveness.
• The end of PTA typically coincides with the end
  of anterograde amnesia, although some survivors
  who have specific and severe deficits in forming
  new memories may experience persistent
  anterograde amnesia despite the resolution of PTA.

38
Memory

• Formal treatment of retrograde amnesia occurs
  primarily during the period of PTA and involves
  exposing the survivor to artifacts from or
  descriptions of major life events in hopes of
  stimulating recall.
• This can be done through review of photo albums,
  and mementos supplied by the family or through
  construction of an autobiographical notebook
  featuring a chronology of major life events
  (e.g., birth, graduation from high school, first
  job, marriage).

39
Memory

• Treatment for anterograde amnesia begins during
  PTA but may extend into later stages of recovery
  based on the particular constellation of memory
  problems displayed by an individual survivor.
• Initial treatment strategies are similar to those
  used to facilitate recovery of orientation--provis
  ion of verbal prompts and environmental cues.
• One of the most frequently used techniques is to
  record daily events in a memory log or journal.

40
Memory

• Initially, family members and rehabilitation
  staff record journal information.
• Later as survivors regain written language
  skills, they can assume responsibility for
  writing brief synopses of events and activities
  as they occur throughout the day.

41
Secondary Stage of Recovery

• In addition to orientation, attention, and memory
  challenges, problem solving, executive
  functioning, critical thinking, and psychosocial
  processes can be impaired.
• A decrease in any single aspect of cognition is
  enough to create a negative effect on
  communicative competence and survivors of TBI
  typically experience multiple cognitive
  disruptions simultaneously.

42
Cognitive-Communicative Challenges

• The numerous possible variations and combinations
  of cognitive deficits following TBI complicate
  the process of identifying and describing the
  factors that contribute to cognitive-communicative
  impairments.
• The extent of cognitive impairment tends to
  fluctuate on a daily (sometimes hourly) basis,
  depending on changes in the individual or the
  environment.
• Moreover, cognitive-communicative impairments
  affect overall communicative competence.

43
Cognitive-Communicative Challenges

• Typically, survivors of TBI with these types of
  impairments have intact grammar and vocabulary
  knowledge, but they cannot participate
  efficiently and effectively in communicative
  exchanges.
• In other words, they talk better than they
  communicate.
• A large number of behaviors associated with
  cognitive-communicative impairments fall under
  the broad category of pragmatics.

44
Cognitive-Communicative Challenges

• However, the specific constellation of behaviors
  associated with an individual survivor's
  cognitive- communicative impairment depends on
  his/her particular set of cognitive strengths and
  challenges.
• Many of the symptoms of cognitive-communication
  impairments are readily apparent in the discourse
  of people with TBI.
• Characteristics of cognitive-communicative
  impairments include

45
Cognitive-Communicative Challenges

• Verbal disfluency
• Lack of cohesion
• Lack of saliency
• Revision
• Tangential speech
• Topic shading
• Lability
• Word finding
• Poor presupposition and
• Irrelevant information.

46
Cognitive-Communicative Challenges

• In particular, discourse is frequently rambling
  with inclusion of many irrelevant details.
• Syntactic and morphological structures are fairly
  intact.

47
Cognitive-Communicative Rehabilitation

• Several considerations guide the development of
  appropriate cognitive-communication treatment
  plans for survivors.
• First and foremost, program plans must be
  individualized.
• The clinician must determine how underlying
  impairments in cognition and communication (e.g.,
  deficits in memory, problem solving, attention,
  and reasoning) contribute to current disabilities
  (e.g., the inability to work, attend school,
  participate in community and leisure activities).

48
Cognitive-Communicative Rehabilitation

• A second consideration is the need for
  multidisciplinary input when developing a plan of
  treatment.
• With input of family members and survivors, the
  team of professionals and family identify current
  disabilities as well as activities that were
  important prior to injury and will continue to be
  important post-injury.
• Once important activities are targeted, task
  analysis should be undertaken to identifying
  component parts of these activities to determine
  where in the activity support is needed and what
  kind of support.

49
Cognitive-Communicative Rehabilitation

• When targeting impairments and disabilities,
  clinicians should use personally relevant
  materials and implement activities in settings
  consistent with preinjury lifestyles.
• Multiple survivors may have apparently similar
  deficits in a particular area of functioning, but
  because of individuals differences prior to
  injury, the effect on each persons life will be
  unique.
• Personally relevant materials provide a means of
  increasing the functionality of treatment and
  facilitate awareness of how deficits negatively
  affect daily life.

50
Cognitive-Communicative Rehabilitation

• Positive routines and scripts should be
  structured.
• Routines and scripts--organized internal (mental)
  representations of events, with their people,
  places, associated objects, associated language,
  and their organization--occur in the course of
  everyday social, familial, vocational,
  recreational, and educational life, and involve
  everyday communication partners, including family
  members, friends, work supervisors, and teachers.

51
Cognitive-Communicative Rehabilitation

• With functional intervention, clinicians learn to
  move beyond commercial therapy materials, generic
  therapy activities, and exclusively clinical
  intervention settings to capitalize on activities
  that are part of the individuals daily
  behavioral repertoire (routine) and to utilize
  everyday communication partners as collaborators
  in intervention (scripts).
• Within an everyday, routine-based approach to
  intervention, people with disability are provided
  with the supports or scaffolds needed to be
  successful.
• The functional everyday approach to
  rehabilitation consists of a progression of
  collaborative steps.

52
Scaffolds to Successful Collaboration

• First, staff and everyday people (ideally
  including the TBI survivor) collaborate to
  identify what is and is not working in the
  everyday routines of life.
• Second, the same group of collaborators
  identifies what changes in everyday routines
  (e.g., environment, behavior of others, behavior
  of survivor) are needed to transform negative,
  unsuccessful routines into positive, successful
  routines and build repertoires of positive
  behavior.

53
Scaffolds to Successful Collaboration

• Thirdly, these same persons identify the supports
  and motivators needed for positive changes in
  everyday routines.
• Fourthly, implement whatever supports (e.g.,
  external aids, compensatory skills) are necessary
  for intensive practice of positive routines in
  real-world contexts.
• Finally, systematically reduced/withdraw levels
  of support and expand contexts as they become
  possible.

54
Treatment Plans Settings

• Treatment plans include both long-term and
  short-term goals.
• Long-term goals directly and functionally address
  a survivors usual and customary day-to-day
  living skills.
• Short-terms goals address underlying impairments
  that negatively affect a survivors independent
  performance of activities identified in long-term
  goals.
• Initial treatment for underlying impairments or
  cognitive subskills is usually provided in
  individual or small group settings.

55
Treatment Plans Settings

• As a survivor masters compensatory techniques,
  treatment should more closely simulate realistic
  and natural settings to create positive change in
  the survivors activity level and participation
  in daily living.
• Moving treatment sessions to functional
  environments, such as a survivors home,
  workplace, or place of leisure, is another way to
  promote carryover of learned compensatory and/or
  accommodation strategies.

56
Goal-Plan-Do-Review Strategy

• One of the ways in which this functional everyday
  approach can be put into action is to first
  organize specific interventions around a general
  Goal-Plan-Do-Review routine.
• Successful people, when faced with a decision (a)
  make choices about what they wish to accomplish
  (b) set reasonable goals for themselves (based on
  their strengths and limitations) (c) create
  intelligent plans for achieving their goals (d)
  act on the plans and (e) review their
  performancewhat worked and what did not work.

57
Goal-Plan-Do-Review Strategy

• Identify what is and is not working for the TBI
  survivor in the everyday routines of life.
• Using the Goal-Plan-Do-Review scaffold, the goal
  portion of the intervention focuses on what
  needs/wants to be accomplished.
• The plan portion addresses materials/equipment
  and steps/assignments needed to accomplish the
  goal and to create daily routines.

58
Goal-Plan-Do-Review Strategy

• The do portion is the action and interaction part
  of the scaffold implemented with identified
  supports and facilitators to achieve positive and
  supported behavior at different levels of
  recovery.
• Finally, the review portion encourages
  self-reflection and feedback about how well the
  goal was accomplished.

59
Goal-Plan-Do-Review Practice

• Before Toms brain injury, he was one of 12
  students, worldwide, selected to study music at a
  conservatory in Europe.
• While he was there, he played with the big
  nameslegends. He was becoming one of THE
  guyslike Kenny G.
• Nine months before Tom left Europe, he married
  his high school sweetheart, Sara.
• Three months before he left Europe, he finished a
  huge CDsolos, duets with the big dogs, some of
  his own compositions, the works.

60
Goal-Plan-Do-Review Practice

• One month before he left Europe, Tom contracted
  an illness that put him in a coma for 8 months.
• Tom and his new bride came home to tears, not
  cheers to a critical care hospital wing, not the
  couples first home to only remnants of dreams
  through CDs and photos.
• It has been 7 years now. Tom cant talk. He can
  hardly hold a spoon. He certainly cant play his
  sax. And Sara, she pretty much takes care of Tom
  full time.

61
Goal-Plan-Do-Review Practice

• They both loved Italian food, gardening, cooking,
  taking pictures, and music.
• Sometimes Tom just seems so sad. Sara seems so
  tired.

62
Cognitive-Communicative Deficits in Dementia

• The functional deficits that individuals with
  dementia experience in communication, activities
  of daily living, and quality of life result
  directly from the cognitive impairments that
  define dementia.
• The patterns of these impairments depends upon
  the distribution of the neuropathology associated
  with the different diseases that cause dementia.
• Historically, clinicians have participated
  extensively in the evaluation process, but have
  been somewhat reluctant to treat this population,
  due to the degenerative nature of the disease.

63
Cognitive-Communicative Deficits in Dementia

• Despite severe impairments in some cognitive
  areas, clinicians should recognize residual
  capacities and utilize them as the springboard
  for successful interventions for dementia
  patients.
• Treatment of patients with dementia will require
  that clinicians focus on developing innovative
  strategies to help clients compensate for the
  their communicative difficulties
• When working with patients with dementia, the
  following principles should be applied.

64
Principles of Intervention in Dementia

• First, reduce demands on episodic
  (autobiographical memory encoded in a
  temporal/spatial context) and working memory
  systems.
• Second, increase reliance on nondeclarative
  memory systems (verbal and motor procedural
  memory subsystems, reflexes, and habit memory).
• Third, provide activities that strengthen lexical
  and conceptual associations.
• Fourth, provide sensory cues that evoke positive
  fact memory, action, and emotion.

65
Spaced Retrieval Strategy

• One general approach to intervention with
  individuals with dementia of the Alzheimers type
  is to capitalize on relatively preserved
  nondeclarative memory abilities.
• The Spaced Retrieval Strategy (Bjork, 1988
  Landauer Bjork, 1978), also referred to as
  Spaced Retrieval Training (SRT Camp, 1996) is a
  treatment method that capitalizes on
  implicitunintentional or nonconscious--learning.
• SRT is frequently used to teach new and forgotten
  information and behaviors to patients with
  dementia.

66
Spaced Retrieval Strategy

• The Spaced Retrieval Strategy (SRS) consists of
  retrieving the information to be learned after
  increasingly longer temporal delays.
• In SRT, a person is told a piece of information
  and then is asked to recall that information
  repeatedly and systematically over time.
• Intervals are manipulated to facilitate
  production of a high number of correct responses
  to the stimulus question and retention of
  information over increasing longer periods of
  time.

67
Spaced Retrieval Strategy

• The temporal delays between retrieval can be
  filled by conversation, playing games, etc.
• SRS has been demonstrated to facilitate
  prospective memory, the ability to remember to
  carry out specified actions at future target
  times.
• The SRS memory method is effortless, because
  the learning seems to occur without full
  cognitive effort on the part of the patient.

68
Spaced Retrieval Strategy

• For example, lets say you want to teach a person
  with AD to use an external memory aid, such as a
  calendar.
• The strategy you want the patient with AD to
  remember is Look at the calendar.
• Present the calendar to the patient and say, How
  are you going to remember what to do each day?
• You want the patient to learn to say Look at my
  calendar.
• With the calendar, orient the patient by saying
  What day is today? What activities are scheduled
  for today? What time is lunch today?

69
Spaced Retrieval Strategy

• After completing orientation to the calendar, the
  patient and clinician would then ask, How do you
  know what you are you going to do today?
• If the response is correct, the clinician would
  go onto another therapy task.
• If the response was incorrect, the clinician
  would provide the correct answer and then
  immediately repeat the prompt question again.
• If the response is correct, the clinician would
  go onto another therapy task and at a natural
  break in the session, the clinician would again
  ask the prompt question.

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Spaced Retrieval Strategy

• When the patient can recall the strategy after a
  one-week interval, SRT is terminated.
• SRT is useful for teaching face-name
  associations, autobiographical information, and
  other compensatory techniques to enhance
  communication.

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Errorless Learning

• Another treatment approach that capitalizes on
  spared memory systems that may be beneficial for
  promoting new learning by individuals with AD is
  errorless learning.
• Errorless learning involves minimization of the
  the number of errors that are allowed to occur
  during learning trials.
• Individuals with episodic memory impairment have
  difficulty eliminating error made during learning
  trials because they cannot explicitly recall the
  learning experience.

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Errorless Learning

• If one use a trial and error approach, these
  individuals will continue to make the same errors
  on subsequent trials rather than learning from
  their errors and making corrections.
• Bourgeois (1990 1992) has demonstrated improved
  functioning in dementia patients by capitalizing
  on spared recognition memory and decreasing
  demands on impaired episodic and working memory
  systems.
• Using memory wallets of photographs of persons
  and places of interest, caregivers can be trained
  to use these wallets in conversation with their
  loved one.

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Errorless Learning

• Bourgeois has found that patients make
  significantly more statements of fact and few
  ambiguous utterances when the wallets are
  present.
• When such as stimulus remains visible in a
  conversation, it alleviates the demands that
  conversation typically places on working memory.
• Additionally, the photographs stimulate
  recognition of episodes and people in the
  patients lives, reducing reliance on free recall
  that usually occurs during conversation about
  remote and recent events.

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Sensory Stimulation Strategy

• Another successful treatment technique evoking
  positive face memory, action, and emotion is the
  use of sensory stimulation.
• Stuffed animals or decorations/knick-knacks found
  in a patients room have been observed to improve
  levels of alertness, positive emotion (smiling
  and nodding), and decreased agitation during
  therapeutic attempts to improve conversation and
  social interaction.

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Montessori-Based Intervention

• A program based on several of the techniques just
  mentioned as well as the life experiences of AD
  patients is the Montessori-based intervention
  developed and described by Camp et al. (1997).
• Montessori programming promotes learning through
  procedural memory processes, and utilizes
  concrete everyday stimuli to facilitate action
  and memory, while reducing demands on episodic
  and working memory by using repeated structured
  tasks and materials.

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Montessori-Based Intervention

• Intergenerational Montessori programming between
  individuals with dementia and children has been
  positive.
• Children are matched with an adult who is a bit
  more cognitively advanced than the child to allow
  the adult to act as the mentor or teacher with
  the child during a Montessori activity, such as
  matching, sorting, or reading aloud.
• Camp, C. J., Judge, K. S., Bye, C. A., Fox, K.
  M., Bowden, J., Bell, M., Valencic, K.,
  Mattern, J.M. (1997). An intergenerational
  program for persons with dementia using
  Montessori methods. The Gerontologist, 37 (5),
  688-692.

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Volunteers in Partnership

• Another type of treatment program that utilizes
  collaboration between volunteers and patients
  with AD is the Volunteers in Partnership (VIP
  Arkin, 1995) program.
• Mild-to-moderate patients with AD are paired with
  university students who assist them in performing
  weekly volunteer services and who provide memory
  and language stimulation.
• Volunteer activities are tailored to each
  patients preferences, and may include helping at
  day-care centers, working at animal shelters, and
  assisting other residents in the nursing home.

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Volunteers in Partnership

• Memory and language tasks are designed by the
  clinician and student are trained to use
  audiotaped quizzes to teach memory for factual
  information and to stimulate language through
  association, picture description, solicitation by
  the student of opinions or advice of how to solve
  real-life problems.
• VIP also has the added benefit of providing
  respite for caregivers.

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Caregiver Functional Communication Training

• For caregivers of AD patients, Ripich (1994) has
  developed a functional communication training
  program called FOCUSED.
• This seven-step program uses each letter in the
  word FOCUSED to refer to a strategy for improving
  communication.
• Ffunctional and face to face
• Oorient to topic
• Cconcrete topics
• Uunstick any communication blocks

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Caregiver Functional Communication Training

• Sstructure with yes/no and choice questions
• Eencourage interaction exchange conversation
• Ddirect, short, simple sentences.