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. And while this material may have seemed stimulating, I did not understand the purpose or clearly see the benefit. That’s when I started asking questions and began researching.
Along the way, I realized that there are a few key takeaways from providing cognitive therapy to patients with dementia. Not only does it help maintain their current level of function and reduce behavioral outbursts, but it also promotes independence within their environment. Once you know the "why" behind cognitive therapy, you can create beneficial techniques to provide assistance.
Whether you’re a new grad SLP and don’t know where to start or if you’re a seasoned clinician looking for new ideas, take a look at the evidence-based therapy techniques below.
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 best way to find out more about your patient, is to ask questions. From there, you can help better determine what therapy techniques would be most beneficial. Whatever cognitive therapy you provide your patient, you want to ensure that it is functional. This way, you can easily identify goals for your patient, and they may be more willing to participate.
Implementation: To start, create a list of questions for yourself to ask your patients with dementia. Use this list as 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, but using a template is a great way to get started. Remember to remain patient, some may need extra time or assistance to answer your questions.
The following are some general open-ended questions that you can use to get started:
- 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 on a normal day?
2. Spaced Retrieval Training
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.
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 set-up 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.
Example: For a patient who used to garden but can no longer bend down to tend to a garden, have them participate in an activity where they must follow directions. Assign them tasks such as planting seeds in pots placed on a table. While any activity can be used, remember to remain creative. You want to keep your patient interested and engaged, to easily set them up for 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 beneficial, with pictures and videos acting as a great tool. Reminiscence therapy can be unstructured with a back-and-forth conversation or structured with the clinician asking open-ended questions.
For example: If you have a picture of the patient on their wedding day, 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 present time while reducing confusion.
Implementation: Reality orientation can be implemented through conversation or with the 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.
Example: A dry erase board can be updated daily to include information such as the date, daily events with timestamps, the weather, 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!