Dementia Treatment in Speech Therapy

What cognitive-communication dementia treatments are best for your speech therapy patients? In this article, we cover evidence-based treatments that aim to improve their communication success, safety, and quality of life.

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More Articles

• Goal Bank for Adult Speech Therapy
• Dementia and Dysphagia
• Memory Book Template for Dementia

Dementia Treatment in Speech Therapy

Keep your dementia treatment interventions meaningful and functional. To do this, interview the patient and caregivers to learn their preferences, daily routines, and history.

Examples of meaningful and functional dementia goal areas:

• Safety
  • Use swallowing strategies
  • Use a call light
  • Lock wheelchair brakes
• Daily activities
  • Check daily schedule
  • Find the bathroom
  • Oral care
• Quality of life
  • Find answers to repetitive questions
  • Make a simple, tasty snack
  • Reminisce with a memory book

Take advantage of your patient’s remaining strengths and skills. With dementia, this usually includes reading, procedural memory, and motor learning. The treatment techniques below will provide plenty of tips for how to do this.

If known, consider the specific disease underlying your patient’s dementia when choosing treatment goals and interventions. Someone with Lewy body disease, for example, may present with sleep and motor disturbances, requiring a special emphasis on scheduling and weighted utensils. While a patient with frontotemporal dementia may present with primary progressive aphasia.

Read Mild Cognitive Impairment vs Dementia.

Caregiver Training

Since dementia is a progressive disease and requires a different approach from acute brain injuries, caregiver training will likely be a big part of every dementia treatment you do. Not only is including caregivers part of person-centered care, but providing training increases the chances of carryover outside of the treatment session.

While there are many different ways to provide caregiver training, keep the following in mind.

Communication Partner Training Tips:

• Include the caregiver in your treatment decisions
• Have the caregiver practice and model back the training to you
• Consider adding videos that support your training
• Ask (and listen!) for feedback

(Folder, N., et al., 2023)

MESSAGE Communication Strategies for Dementia is an evidence-based communication partner training program developed by the University of Queensland. Click here for their free PDF manual.

Treatment Techniques for Dementia

The following are cognitive interventions that have been shown to help patients with dementia remember information and learn new skills. They include spaced retrieval, errorless learning, and chaining (with task analysis).

1. Spaced Retrieval

The goal of spaced retrieval is to help patients remember information, long-term.

This technique is recommended for those with mild to severe cognitive-communication impairments.

To screen whether a patient is a good candidate, do a mini spaced retrieval session. You can fold it into your assessment, or spend a few minutes teaching a simple piece of information, such as your name.

Spaced Retrieval Step-by-Step:

1. Ask the question
   • Ask your patient a specific, open-ended target question
   • “What should you do after taking a bite of food?”
2. Give the correct response
   • “Take a drink”
3. Ask the question again
   • Ask the exact same target question again and wait for an immediate response. The answer should exactly mimic your correct response
   • “Take a drink”
4. If correct, move on to step 5. If incorrect, go back to step 1
5. Wait for 15 seconds, then ask the exact same question again
   • Continue to increase the time between asking the question again
   • Start with 15 seconds, then increase to 30 seconds, 1 minute, 2 minutes, 4 minutes, 8 minutes, etc. You may go up to a half-hour or beyond.
   • Remember, the response must be correct to increase the time interval.
   • If incorrect, go back one time interval (or until they’re successful)

Read Spaced Retrieval For Adult Speech Therapy for more details.

2. Errorless Learning

The aim of errorless learning is for patients with dementia to have as few errors as possible when learning a new skill.

How To Do Errorless Learning:

• The target skill or answer should be specific
  • “I take small bites.”
• First, model the skill or answer
• Then, have the patient practice the correct skill or answer many times
• If the patient makes an error, immediately correct the error
• Emphasize not guessing by giving as many cues as needed
• Pair with spaced retrieval and chaining, as appropriate

3. Chaining (and Task Analysis)

Task analysis teaches a new task by breaking it down into smaller steps. It takes advantage of procedural memory, a common strength of people with dementia. Use task analysis to teach the patient each smaller step, then ‘chain’ them together.

Task Analysis Example: Asking a smart speaker about the weather:

1. Go into the [room where the smart speaker is]
2. Say, “Alexa.”
3. Wait for Alexa to turn blue (or to say “Mmhmm?”)
4. Ask, “What’s the weather?”

Chaining Step-By-Step:

1. Break down the task into key steps
   
2. Fully prompt the patient through each step
   • Give cues and modeling as needed as they go through every step of the task
     
3. Fade prompts for the last step only
   • Go through the entire task, but decrease cues for the last step
   • Keep fading cues until the patient can do the last step independently
     
4. Fade prompts for the 2nd-to-last step
   • Go through the entire task, but decrease cues for the 2nd-to-last step AND last step
   • Keep fading cues until the patient can do these last 2 steps independently
     
5. Keep fading prompts for the entire task
   • Keep backward chaining until the patient does the entire task independently

External Memory Aids

External memory aids are most often written reminders formatted for patients with dementia.

They take advantage of the patient’s preserved abilities (reading, procedural memory, semantic memory, etc.). While taking the pressure off of impairments (working memory, declarative memory, etc.)

External memory aids can support just about every goal area, including safety, orientation, daily activities, and quality of life.

Use the treatment techniques above (spaced retrieval, errorless learning, and chaining) to teach patients how to use these aids.

We’ll cover five helpful external memory aids: memory books, memory wallets, reminder cards, checklists, and good ole’ calendars.

1. Memory Books

A memory book is a personalized, handmade book made up of pictures with corresponding text. The pages are usually printed out and kept in a 3-ring binder or photo album.

The aim of a memory book is to help patients recall information, orient, spark memories, and increase comfort.

Useful pages to include in a memory book are personal memories, family, location information, daily schedule, and answers to repetitive questions.

Formatting tips:

• Large font (at least 24-point, Arial or Calibri font)
• Black text on white paper
• 1 sentence and 1 picture per page
• Capital letter at the beginning of the sentence (not all caps)
• Short, simple sentences
• Laminated or kept in plastic sleeves
• Simple images with max 2 objects or people

Read How to Make A Memory Book for a comprehensive guide and a free PDF template.

2. Memory Wallets

A memory wallet is a pocket-sized memory book. See the formatting tips above.

Consider your patient’s lifestyle, preferences, strengths, and weaknesses when deciding whether to recommend a memory book and/or wallet.

You can make a memory wallet out of index cards on a metal ring. Or use a small photo album with sleeves.

3. Reminder Cards

Reminder cards are written information that reminds a patient of something important. They’re often posted strategically around their environment. As always, the reminder cards are best if functional, meaningful, and formatted for the patient.

Reminder cards can come in many forms. Below are just a few examples of how to use them to support your patient’s goals.

Example Reminder Cards:

• Room number with name posted next to door
• Wheelchair safety attached to wheelchair
• Answer to a repetitive question on a lanyard
• Bathroom sign
• Personal identification card kept in wallet
• Daily schedule on the refrigerator
• Swallowing strategy framed on the dining table
• Labels in the closet
• Discussion cards during group discussions
• Modified recipe card taken out when grandchild visit

Formatting Reminder Cards:

• Large font (individualize for each patient)
• Arial or Calibri font 
• High contrast (black ink on white paper, white ink on blue or kelly-green paper)
• Capital letter at the beginning of the sentence (not all caps)
• Short and simple sentences
• Use a brightly colored background vs white background (e.g. glue the sign onto a brightly colored piece of paper)
• Choose a contrasting color (from the door/wall it will be posted on)
• Use consistently colored signs throughout the environment. For example, all signs in the bedroom should be the same color
• Accessible! (posted at patient’s eye level, attached to wheelchair, etc.)
• Train patients how to use it!

4. Checklists

Checklists are a type of reminder card that serve the extra purpose of walking a patient through a task to increase independence. Collaborate with occupational therapy as appropriate.

Example Checklists:

• Swallowing strategies
• Transferring safely from a chair
• Joint replacement precautions
• Medication management
• Hobbies and meaningful tasks (cooking, gardening, using the TV)
• Oral care

5. Calendars

Use calendars to help patients remember appointments, know their daily schedule, orient, jog their memories, and answer repetitive questions.

Formatting Calendars:

• Consider dry-erase calendars
• Post strategically (on the refrigerator or dining table)
• Use high contrast (dark ink on white background)
• Write legibly
• Use keywords

Read Speech Therapy Exercises Using A Calendar.

Cognitive Stimulation

Cognitive stimulation is a dementia treatment intervention that:

• Stimulates general cognition
• Involves a range of activities (medication management, meal planning, etc.)
• Is usually done in a small group (but can be done one-on-one)

A systematic review found that cognitive stimulation led to consistent improvements in cognition, communication, social interaction, and self-rated well-being and quality of life (Aguirre, E. et al. 2013).

So how do you actually do it?

One option is to try Cognitive Stimulation Therapy, a 14-session, evidence-based program developed by Aimee Spector of the University of London. You can follow the manual or take a training course (available for purchase on their website).

You can also design your own cognitive stimulation sessions with activities that:

• Are the just right challenge (takes effort but not too hard)
• Stimulate cognition and language in a way that’s engaging and fun (activities, discussions)
• Are new and varied
• Add in physical activity (gardening, lawn games, dancing)
• Include peers, if possible

Montessori for Dementia

Montessori is a philosophical approach to aging and dementia.

Rather than a specific method of stimulating cognition and communication, the Montessori approach designs the environment to nurture the needs, interests, and abilities of the person with dementia.

Hallmarks of the Montessori approach for dementia:

• Materials that are neatly organized, labeled, and easy to access
• An environment where hands-on, individual-led activities are available at all times
• Activities are joyful, engaging, and satisfying
• An emphasis on maximizing choice, freedom of movement, and independence
• Lots of visual aids

While you likely can’t do a complete makeover of every patient’s environment, you can keep the Montessori approach in mind when designing your treatments and educating caregivers.

Keep scrolling for practical ways to modify the patient’s environment.

Environmental Modifications

Modifying the environment can support your speech therapy goals while improving your patient with dementia’s overall safety, independence, and quality of life.

1. Improve Lighting

Both advanced age and dementia impact vision. Improve lighting to help patients see, increase participation, and decrease discomfort and agitation.

How to improve lighting:

• Turn on more lights or move closer to a light source
• Add in some natural light (open blinds)
• Add lighting to dark spaces (closets, corners)
• When possible, choose lights that shine up but not into people’s eyes (lamps)
• When possible, avoid fluorescent lights
• Avoid flickering lights
• Avoid glare (cover shiny surfaces)
• Avoid sudden changes in light levels (instead, have consistent lighting throughout; take breaks when moving inside or outside)

2. Add Visual Contrast

Use high visual contrast between the target object you want a patient with dementia to focus on and the background.

Examples of visual contrast:

• A plate that contrasts with the table/placemat
• A placemat that contrasts with the table color
• A sign that contrasts with the wall
• High-contrast colors to highlight an obstacle (step)
• High-contrast colors to highlight other important items (bright-colored tape around a light switch)
• An important door painted a contrasting color (bathroom door, closet door)

3. Improve the Auditory Environment

Support your speech therapy sessions by reducing competing sounds.

Ways to do this:

• Close the window or door
• Turn off the TV or radio
• Ask others to leave the room
• Close curtains to dampen sound
• Move to a space with better acoustics (carpets, curtains, quiet)

Make sure that your patient’s hearing aids are on and working! This not only improves engagement but may also reduce cognitive decline.

4. Improve the Physical Environment

Ask caregivers to help modify your patient’s physical environment.

The goal is to create an intentional yet low-stimulation and comfortable space.

Do this by showcasing items that support orientation, safety, meaningful activity, and comfort–while removing distractions.

Ways to do this:

• Reduce clutter
• Arrange furniture in an organized way
• Organize the environment with bins, shelving, etc.
• Showcase meaningful items (favorite blanket, framed photos, memory book)
• Have self-directed, meaningful activities that are organized and easy to access (hobbies, radio, reading material)
• Post a digital wall clock with large numbers in clear view of the patient
• Post signs to support safety and orientation
• Post a large monthly calendar and/or memo board
• Provide plenty of the right type of lighting
• Add visual contrast

5. Add Comfort

Consider adding comfort to the environment during your treatment session to help decrease agitation and improve participation.

Use your best judgment when deciding which of the ideas below are appropriate for each individual patient.

Ways to add comfort:

• Warm blanket and mittens
• Doll or stuffed animal
• A pet
• Adjust the temperature
• Plants (non-toxic)
• Appealing smells (essential oils)
• Clear line of sight to a restroom (keep bathroom door open, add a sign)
• Remove or cover mirrors

Other Memory Treatment Ideas

Read Speech Therapy Memory Activities for Adults: A Practical Guide for treatment ideas organized by severity of memory impairment.

More Resources

See what speech-language pathologists are saying about The Adult Speech Therapy Starter Pack!

References

• _{Aguirre, E., Woods, R. T., Spector, A., & Orrell, M. (2013). Cognitive stimulation for dementia: A systematic review of the evidence of effectiveness from randomised controlled trials. Ageing Research Reviews, 12(1), 253-262. https://doi.org/10.1016/j.arr.2012.07.001}
• _{American Speech-Language-Hearing Association (n.d.). Dementia (Practice Portal). Retrieved August, 31, 2023, from www.asha.org/Practice-Portal/Clinical-Topics/Dementia/.}
• _{Benigas, J.E. (n.d.) External Memory Aids and Memory Books for Memory Loss. Medbridge. https://www.medbridge.com/course-catalog/details/external-memory-aids-and-memory-books-for-memory-loss-jeanette-benigas/}
• _{Benigas, J.E. (n.d.) Spaced retrieval for memory loss part 1: screenings, development, and support. Medbridge.
  https://www.medbridgeeducation.com/courses/details/spaced-retrieval-for-memory-loss-part-1-screenings-development-and-support-jeanette-benigas}
• _{Benigas, J.E. (n.d.) Spaced retrieval for memory loss part 2: implementation strategies. Medbridge. https://www.medbridgeeducation.com/courses/details/spaced-retrieval-for-memory-loss-part-1-screenings-development-and-support-jeanette-benigas}
• _{Brush, J. (2018, April). Tips for Creating Signs – Dementia Care Training & Education | Redesigning Dementia Care. Brush Development. Retrieved August 10, 2023, from https://brushdevelopment.com/tips-creating-signs/}
• _{Brush, J., & Bourgeois, M. (2020). Montessori Developmental Principles to Support the Needs of the Elderly. Association Montessori Internationale. https://doi.org/2020}
• _{Brush, J., Fleder, H., & Calkins, M. (2012). Using the Environment to Support Communication and Foster Independence in People with Dementia: A review of case studies in long term care settings. Kirtland, Ohio: I.D.E.A.S., Inc.}
• _{Cicerone, K. et al.(2019). ACRM Cognitive Rehabilitation Manual & Textbook Second Edition. American Congress of Rehabilitation Medicine. https://acrm.org/meetings/cognitive-rehab-training-second-edition/}
• _{De Wit, L., et al. (2021). Procedural Learning in Individuals with Amnestic Mild Cognitive Impairment and Alzheimer’s Dementia: a Systematic Review and Meta-analysis. Neuropsychology review, 31(1), 103–114. https://doi.org/10.1007/s11065-020-09449-1}
• _{Folder, N., et al. The Effectiveness and Characteristics of Communication Partner Training Programs for Families of People With Dementia: A Systematic Review. The Gerontologist. https://doi.org/10.1093/geront/gnad095}
• _{Hickey, E.M. (n.d.) Interventions for Persons with Dementia: Creating Supportive Environments. Medbridge. https://www.medbridgeeducation.com/courses/details/interventions-for-persons-with-dementia-creating-supportive-environments}
• _{Hopper, T., et al. (2005). Evidence-based practice recommendations for working with individuals with dementia: Spaced-retrieval training. Journal of Medical Speech-Language Pathology, 13(4), xxvii-xxxiv.}
• _{Lanzi, A., et al. (2017). Person-Centered Memory and Communication Strategies for Adults With Dementia. Topics in Language Disorders, 37(4), 361-374. https://www.researchgate.net/publication/320641614_Person-Centered_Memory_and_Communication_Strategies_for_Adults_With_Dementia}
• _{Oren S, Willerton C, Small J. Effects of spaced retrieval training on semantic memory in Alzheimer’s disease: a systematic review. J Speech Lang Hear Res. 2014 Feb;57(1):247-70.}