As a new clinician, I struggled with providing cognitive therapy to my patients with dementia. I would give them word finds, crossword puzzles, and other simple worksheets to pass the time; however, while this material may have been stimulating them, I did not understand the purpose or see the benefit. That’s when I started asking questions and researching.
In asking professors and supervisors for guidance and doing some research, I realized that there are a couple of purposes to cognitive therapy for those with dementia. The key purposes that stuck out to me were to help patients maintain their current level of function, reduce behavioral outbursts, and promote independence within their environment. Once I knew the purpose and overall goal, I was able to better create activities to address these areas. My research also helped me to discover different evidence-based techniques that may benefit this population.
If you’re a new grad SLP and don’t know where to start (like I was), or if you’re a seasoned clinician looking for new ideas, take a look at these evidence-based therapy techniques.
1. Ask Your Patients Questions
Okay, this one is not necessarily an evidence-based therapy technique, but it is vital to overall success.
Purpose: The purpose of asking questions is to find out more about your patient and to help you better determine what therapy techniques may benefit them. My main concern when providing cognitive therapy is to ensure that it is functional. When it is functional, you are able to more easily identify goals, the patient may have a better awareness of the purpose of therapy, and the patient may be more willing to participate. Finding out about a patient’s daily life is the best place to start when working to make treatment functional for them.
Implementation: I recommend creating a list of questions for yourself to always ask your patients who have dementia. This list can be your starting point to identify the patient’s wants, needs, desires, and remaining abilities. As you ask questions, you may choose to deviate from your list, add more, or remove some, but I find having a template is a great way to get started. Remember to be patient and dig a little bit. Sometimes patients need extra time or some help to answer these questions.
For example: The following are some general open-ended questions that you can build off of:
- What do you want to be able to do better?
- What makes your day more difficult?
- What are your interests?
- Do you have any hobbies?
- What do you do in a normal day?
2. Spaced Retrieval Training
I was introduced to this technique during my CFY and have been learning more about it and using it ever since. I have personally had great success with this one.
Purpose: Spaced retrieval allows patients to remember meaningful information over progressively longer periods of time.
Implementation: Work with your patient to identify targets such as important names, place of residence, swallowing strategies, memory aids, etc. Once a target has been decided upon, wait 15 seconds and then ask your patient a question with the target as the anticipated response. If they answer correctly, double the time interval to 30 seconds and ask again. You continue to double the time interval as long as the patient provides accurate responses. If an inaccurate response is provided, you should immediately provide the correct response then return to the last time interval that was properly achieved.
For example: Your client wants to remember a swallow strategy to alternate liquids and solids. So you may begin by saying, “Your swallow strategy is to alternate liquids and solids.” Then wait 15 seconds and your question to them might be, “What is your swallow strategy?” The anticipated response is, “Alternate liquids and solids.” If the patient responds properly, continue on to your 30-second delay. If the patient does not respond accurately, correct them and try again. If they cannot achieve a 15-second recall time, you may want to attempt a different therapy technique.
3. Montessori-Based Interventions
This one is not necessarily a therapeutic technique, but rather a way to help you as a therapist set up the patient’s environment.
Purpose: The Montessori-Based Intervention addresses environmental manipulation and setup to promote interest, engagement, and success.
Implementation: Identify the patient’s interests and assess their abilities to participate in activities. Are they able to read, write, walk, hear, speak, etc.? Once you have done this, you can then create activities with this information in mind.
For example: For a patient who used to be a gardener but cannot bend down to tend the garden, you can have them participate in an activity addressing following directions and attention to task through planting seeds in small pots that are placed on a table. Any activity can be used, just be creative. The important thing is to make sure the patient is interested, engaged, and their environment is set up to promote success.
4. Reminiscence Therapy
Purpose: Reminiscence therapy stimulates a patient through conversation and prompts them to reconnect to past events. The patient may be able to participate in a meaningful back and forth conversation about such events.
Implementation: Your ability to utilize reminiscence therapy will greatly depend upon your ability to access accurate information from the patient’s past. For this reason, connecting with a close loved one would be greatly beneficial. You may also decide to train a loved one on how to utilize this technique. Pictures or videos are a great tool to assist in this therapy. Reminiscence therapy can be unstructured with a back-and-forth conversation or structured through use of pictures or videos or other tactile objects with the clinician asking open-ended questions.
For example: If you have a picture of the patient on their wedding day you would show them the picture and ask them questions such as, “Who is in this picture?” “What event was occurring?” “When was the wedding?” “Where did it take place?” “What are some wedding gifts that you received?” The patient may also have objects that they can discuss with you such as a piece of jewelry, an antique piece of furniture, a blanket they made years ago, etc.
5. Reality Orientation
Purpose: This technique is used to help reorient the patient to the here and now and reduce confusion.
Implementation: Reality orientation can be implemented through conversation or with use of visual props. In conversation, you would speak with the patient frequently reiterating the date, time, and location. You should also frequently address the client by their name throughout the conversation. Use of visual props may include a dry erase board, pictures, calendars, clocks, visual reminders, etc.
For example: A dry erase board can be updated daily to include information such as the date, daily events with times they are occurring, the weather for the day, etc. Pictures can be discussed in conversation and you can also put labels on the pictures to help identify the people in them. Speaking of labels, you can also label cabinets/closets/doors to identify what is in them for ease of finding items and to reduce rummaging. It is important to remember that any visual props used should be placed in an easy to see location.
There are lots of great resources out there that expand upon these recommended techniques. There are also a lot of continuing education courses that cover cognitive therapy techniques.
What techniques do you use for cognitive therapy? Tell us in the comments!