Friday, July 25, 2014

Functional Maintenance Program for Residents with Dementia (Long Term Care Settings)

I recently attended a very informative seminar through Consultants in Dementia. I highly recommend it to those of you working in the skilled nursing environment. One of the things that has really helped me improve performance within this complex population is the establishment of a Functional Maintenance Program (FMP). In order to get this going at my facility, I had to create a proposal of the steps involved and what it would look like. I'd like to share this with you:

       Establishing A Functional Maintenance Program (FMP)

Materials needed:

Two 3 ring bingers with alphabetical tab dividers
2 large cabinets with at least 3 shelves that can fit up to 8 bins per shelf (preferably adjustable shelving for varying heights of materials)
Locks for the cabinets (key or number code)
If key locks, then a key holder similar to the restroom key for staff to retrieve at nursing station
Materials for the selected activities (to be purchased by the SLP under the FMP budget)
Either a table suitable for 4 wheelchairs at the north and south end OR at least two roll out tables next to the cabinets labeled “For FMP only”

Steps and Documentation:

Evaluation by Speech-Language Pathologist (SLP) with goals written for completion of FMP
An annual inservice for all of nursing (DON, RN, CNAs, managers) with SLP to understand the process. Paperwork will be signed by all attendees for this inservice (approximately 20 minutes)
Once FMP is established by the SLP, the Director of Nursing will sign off on the plan and the original will be placed in the resident’s medical chart with a copy going in the FMP binder 
SLP will document ongoing training with nursing for each resident within their treatment sessions
Nursing is to pass information on to CNAs for their shift until this system becomes routine
The Activities Director will add identified residents to selected activities by the SLP for both group and 1:1 sessions to be documented in their care plans
It takes 3 months of repetition and consistency for a system to be created; therefore the first 3 months will consume the most time. This is critical however for a simplistic system that will require very little maintenance once established.

How the program works once established:

The SLP will evaluate individuals that are in need of maintaining preserved skills due to dementia. Through treatment sessions the SLP will discover activities that are enjoyable to the resident and easiest for them to perform independently. This can be as basic as folding towels, arranging fake flowers, and coloring, to strategy games such as checkers or chess. The long term memory is most preserved within dementia, so finding activities that they once performed repeatedly in their lives will help maintain their preserved skills within attention, memory and problem solving. This can carry over into areas of safety. As well, residents with dementia desire to be functioning and will get restless when sitting in their wheelchairs too long, putting them at high risk for falls. Knowing their preferred activities and providing them regularly and/or when signs of restlessness appear (e.g., trying to get up from wheelchair, behavioral outbursts) can reduce negative incidents. 
Once the SLP has determined the activities best suited for the resident, a list will be created and reviewed with nursing. Brief training will take place for the primary nurse and CNAs available during that treatment time. 
The north and south end of the building will each need cabinets that can be locked, keeping the key at an identified spot in the nursing station for easy access of all staff members. In this cabinet will be a notebook that will have each identified resident’s FMP sheet which will list their preferred activities (simply look up the patient’s last name). There will be bins within this cabinet for residents on the plan with special activities unique to them as well as general bins in which the activities may be a shared interest. 
As staff becomes familiar with the preferred activities of the residents, the redirection of undesired behaviors and establishing routines should become a fairly quick transition. 
In addition to the FMP, identified residents will be placed on Activities list for 1:1 activities as well as group activities to promote socialization and more structured interactions. 

Keeping our residents with dementia engaging in activities appropriate to their skill level will decrease requests for help, attempts to get up from wheelchair and behavioral outbursts. It also has the potential to improve upon existing skills, requiring less dependence on their caregivers. 




Thursday, July 7, 2011

Speech Exercises, By Ann-Marie Elia, M.A., CCC-SLP

The following is a compilation of speech and oral motor exercises for dysarthric patients. It can also be modified and used for accent reduction and other articulation impairments.

Speech Exercises

Top 10 Must-Dos For Memory, By Ann-Marie Elia, M.A., CCC-SLP

1.      Write daily activities down in a notebook/journal. This is good for memory recall of that particular day. Then you can use the notebook/journal to test your memory one week later by trying to recall again what you did on that day. See if what you recall matches what you wrote down in the notebook/journal.

2.      Keep track of appointments on a calendar and keep your calendar visible (on the refrigerator, hanging on wall) if possible.

3.      Keep track of important information (your address, bank account information, doctor’s number, etc) within one location, such as a notebook or PDA. Have an emergency copy in a second location. Having a travel sized copy is very useful for when you are on the go and need to have access to such information.

4.      Keep belongings you use day to day in the same location, such as your car keys. This helps to reduce time spent looking for items.

5.       Set alarms (on your cell phone, PDA, or digital timer) to keep you on track for various tasks and assist with time management. This can range from keeping track of appointments to keeping track of how long you have something cooking in the oven. Even if you feel this is not necessary, setting such reminders actually assists with your memory recall. Plus, it’s a great “back-up” plan if you do happen to forget.

6.      Try to always have access to a mini-notebook or sticky pad for situations that come up where you need to remember information, such as writing down where you parked your car. A PDA is also great for this.

7.      Keep track of any “memory event” you might have. Whether it was repeating information to a friend, or forgetting an appointment. Keeping track will allow you to increase your awareness of just how often these events are happening. Write down what was happening at the time. Was it a loud environment? Were you tired? Did you notice the error, or did someone else have to tell you? This serves as a great resource for your doctor as well.

8.      Keep stress to a minimum, eat well and get plenty of sleep. These factors can magnify cognitive/brain impairments if not managed and could possible put you in danger (driving a car, crossing the road). Balance is the key to a healthy mind.

9.      Maintaining a regular cardio exercise program increases blood flow and oxygen to the brain. Consult with your doctor concerning your limitations.

10. At least once a day, take time to do your cognitive/brain exercises. Your brain, much like the muscles in your body, needs to be used in order to maintain its functions. As they say, “Use it or lose it”.  

Intensive Rehabilitation Programs

I have read some great research articles concerning mass practice and the reorganization of the brain. Some of those articles are posted on this site. Even with this understanding, I was still asking...almost pleading...that my patients with neuro impairments do an hour of my recommended exercises per day. Then new changes were occurring within my outpatient hospital setting that would cut back therapy time from 1 hour to 45 minutes with my patients. I was told it may soon go down to 30 minutes and I was only able to see these people 2, maybe 3 times per week depending on their insurance. It was a helpless feeling at first. Then it occurred to me. I haven't been pushing my patients hard enough out of fear they wouldn't perform or would quit and not come back. I wasn't even giving them the benefit of the doubt that they would WANT to work hard towards their recovery. Let's face it, there is no magic wand currently for brain cell recovery and rewiring the brain. Rewiring the brain requires commitment and hours and hours of practice. Even with my 1 hour weekly sessions I would not get the results my patients wanted. So I developed a more intensive program of 4 consecutive hours a day for 5 days per week. For some, they would have to build up to being able to mentally tolerate 4 consecutive hours. Areas targeted were the identified impairments and breaks were encouraged to be no more than 5-10 minutes between these targeted areas. As part of my patient's goal, I would have them learn how to be their own therapist. If they were not cognitively intact enough for that goal, I would make it the goal for the significant other/caregiver. They would have to demonstrate knowledge of restorative exercises AND compensatory strategies for identified impairments. If the patient understands this, they are on their way to being their own healer. If the loved one understands this, they are on their way to being a healer themselves and can eventually delegate roles to other loved ones for further support in the patient's recovery. Patients must understand that there is no quick solution. Like an Olympic athlete who must put in countless hours of training for superior results, so must our patients with neurological challenges. As a therapist, we better serve these patients by empowering them and their families. I've attached examples of my programs. Of course each patient has different goals and you adjust accordingly. If a patient has mild cognitive impairments and are working a full time job/full time in school, I put them on a daily program for one hour (maybe more depending on work/school load) with no break in that hour+ for 5 days a week. I found this program frees up my therapy time to introduce resources to them and how to find more resources. We can also focus on more functional tasks instead of the drill and kill since they are doing that at home. There will be some patients/significant others/caregivers that this program is not suitable for, and that is where your assessment skills as a therapist will serve you. My feeling is we can at the very least offer these tools and strive for greater independence with our patients. If they are not ready for this level of intensity, you can build them up towards it as a goal. This is a complicated subject matter that I am trying to simplify within the context of this blog. Hopefully, it will be helpful in enhancing your ideas and current home exercise program for the people that you are working with.

The following is a link to a zip file with examples of home programs from 1-4 hours to be performed consecutively (with 5-10 minutes break max between areas) and handouts with resources: Home Programs and Resource Hand-Outs_Examples

Friday, May 14, 2010

Emotional Worksheet, by Nic Cerney (2010 SDSU Graduate Student)

Emotion Thermometer

Purpose: To help children with pragmatic impairments (e.g., children with autism spectrum disorder) understand different emotions, regulate their own emotions, and become conscious of other individual’s feelings.

Step 1: Introduce the Thermometer

Emotion Thermometer Worksheet
- Pass out the emotion thermometer worksheet. You may want to fold the worksheet in a way that hides the table and shows only the thermometer to direct the child’s attention solely to the thermometer.
- Ask the child what they know about a thermometer. What does it look like? What can it be used for?
- Explain that emotions can be measured the same way. Start with a positive emotion as an example (e.g., happy). Ask about times and/or situations when the child has felt a little happy vs. very happy.

Step 2: Label the Thermometer
- If the child is old enough, have her/him look up the emotion in the thesaurus and have her/him choose a total of ten synonyms for that emotion.
- Type the ten words onto sticky labels, and have the child place the labels on the thermometer depending on how she/he feels the emotions should be ranked on the one-to-ten scale.

Step 3: Create a Poster
- Once the child has labeled the thermometer, you may re-draw her/his thermometer onto poster paper. Use magazines to look for pictures of people that represent each emotion on her/his thermometer, and glue the pictures onto the poster in the appropriate places.
- Then, you may write different scenarios onto Post-It notes and have the child place those on the giant thermometer depending on how the child or an individual would feel in that situation.

Step 4: Fill in the Table
- In the “Metaphors” column, draw pictures of a metaphor that symbolizes the emotion at different points of the thermometer (e.g., fireworks for “happy” or a volcano erupting for “angry”).
- In the “Looks Like” column, draw a picture of what one’s face looks like at each point on the thermometer.
- In the “Sounds like” column, write what one would say or think at each point on the thermometer.
- In the “I can Try…” column, think of strategies the child can use depending on how they feel on the thermometer (used primarily for negative emotions).
- To generalize these skills, write the strategies down in an “Emotion Toolbox,” i.e., a portable notepad they can refer to in the classroom, at home, on the playground, etc., when they experience that particular emotion.

Metacognitive Approach, by Carry Baker (2010 SDSU Graduate Student)

I really wanted my students to have skills that would generalize to their classroom and design a therapy plan that could be used for any age group and any language (e.g., inferencing is universal, building off each others ideas are universal, etc.)

The powerpoint contains my goals for myself for therapy that would be functional. I wanted my students to know what to do when they would be confronted with the same format in their classrooms. How do you discuss a book after your teacher has just read it with a group of students? I also always addressed meta-cognition, how do you know what you know? It took weeks for some of my students to know how to answer this, and some of them still don't, but the students who do know how to answer are great models.
I also wanted my students to be self-advocates; when they didn't know an answer I wanted them to seek clarification. This skill also took weeks and I surprisingly saw the most improvement from my 5th grade special day class group. I finally saw this skill begin to development after they were able to feel successful and comfortable making mistakes before being able to independently raise their hand and say, "I still don't get it." It saves a lot of time when they can just tell you the parts they don't understand.

The powerpoint also contains books with emotional hooks I chose that were not discussed in their classrooms that were received well by all my students. For students with difficulty with decoding, there are Jack & Julie stories as well as George and Martha stories, both are great for inferencing and developing other high level narrative skills without being overwhelmed with text. As well as the Jack & Julie story suggestion for those students (or ALL your students, which is how I felt) who have difficulty with Theory of Mind skills (e.g., taking the listener perspective). All syntax and semantic goals were embedded. I focused on words using the "Bring Words to LIfe" book model. Syntax was addressed when the students asked questions or made comments (e.g., Student: "He goed to the store." Me: "When someone already did something, it happened in the past and instead of 'goed' we say went", etc.) All of the books I shared were discussed like how we were shown at the language and literacy conference, the higher level thinking was the focus and we had discussions at natural important points of the story.

I really focused on the "Talking about the Text" rubric we received at the language and literacy conference. That is how my Master SLP had been doing language therapy before I got there, but the rubric offered a way to track progress (e.g., giving the groups a score after each session that they could relate to their state testing standards) as well as have a visual for the students to know what was expected of them. All of the groups were motivated to raise both of their scores, all of them wanted 4's in both categories. I would simply have a sticky note with their names and place it where they were.

I also had a data sheet with information as an addition to the reading rubric that would help track some more specific skills of the students. This challenged the students higher level thinking versus reporting facts from a story. It was just a way to track how the student's thinking was progressing. And the bottom portion contains a spot to list the students' names & their level of support (e.g., min-max) that was needed for that session.


Language Therapy Power Point
Talking About the Text
Reading Data Sheet

Pragmatics and Complexity Articulation Approach, by Julia O’Brien (2010 SDSU Graduate Student)

Below is a lesson on reading body language and increasing vocabulary needed to express emotion.
Theret is also an example of how to implement the complexity approach in articulation therapy. Specifically I used the /thr-/ and /spl-/ blends. Characters and a simple story line are created, the words practiced, the book mastered and ownership taken by the kiddos. It is their story with themselves actually in the story so this is usually very successful. 

Reading Facial Expressions/Working Memory

Skills to be addresses in this activity:
Making inferential guesses
Identifying possible emotion through facial expression
Turn taking
Listening to other group members
Increased vocabulary
Working memory
Encourages participation
Encourages individuality

Goal of activity:
1. Increase the student’s ability to make inferences about the person based on their facial expressions.
2. Increase awareness of what someone else may be telling us through their emotion and facial expression.
3. Increase vocabulary of “feeling/emotion” words.

Prior to activity with students
1. Cut out a variety of pictures of faces from magazines, catalogues, etc. Make sure to have a wide range of facial expressions, ages and ethnicities of people and place them all in a bag.
2. Cut out individual facial features (eyes, nose, mouth, etc.) from larger pictures & place in a small bag
3. Print a silhouette cartoon head.

Procedures
- Identify that students are not to use the “easy” words Happy, Sad or Mad.
- Have each student pick a face and give a description of how that person may be feeling. Ask them why they think happened to that person to make them feel that way.
- Write words on the board and have the kids show their example of each word as it gets added to the list (i.e. surprised, lonely, thrilled, excited, etc.)
- Some kids may give an action that describes what the person is doing (i.e. smiling, laughing, crying), so discuss how you may feel while doing that action.
- Continue as long as time permits and every student has had multiple chances to participate.

- Have each student pick one feature from the bag of individual features. 
- Have each student glue on their feature onto the silhouette
- Have the group name the person (i.e. Jackson Montgomery)
- Introduce the working memory task. “Jackson Montgomery is going on a camping trip (or going to the beach or going on summer vacation, etc.) and the first thing he wants to do is _________.
- The next student has to recall the entirety of the story, retell it aloud and add another activity.
- If the students can’t remember, he/she can ask for a hint. The student who’s activity can’t be recalled can give a clue. (Giving clues is hard for them so its good practice to give some information without giving the exact answer).
- If working memory skills are not very strong, encourage the kids to think of really silly activities because they have a tendency to laugh about it and recall it with greater ease.

 Book with target Articulation sounds /spl-/ and /thr-/

If you have decided that your student would benefit from the /spl-/ or the /thr-/blend (complexity approach) for phonology treatment, make a book of target words that the kids will learn, rehearse and master.

Splumu (monster)
Sploony (monster) (the two are best friends but want more friends)
Spleet (the planet they live on)
Splum (what they like to eat)

Thromo (monster)
Thrattle  (monster) (the two are best friends but want more friends)
Throot  (the planet they live on)
Thram (what they like to eat)

Example of story: (each page has a picture)
Pg 1 This is Splumu
Pg 2 This is his best friend Sploony
Pg 3  Splumu and Sploony live on the planet Spleet
Pg 4  Splumu likes to eat splum
Pg 5 Splumu wants to visit earth
Pg 6 Splumu wants to meet Billy (Name of child here)
Pg 7 Billy wants to play baseball (child’s favorite hobby here)  with Splumu.
Pg 8 Splumu and Sploony come to earth to meet Billy and they become good friends.

The kids get to color the pages of the story and once the book is mastered, the child gets to read it in front of his/her class if desired. Practicing their words knowing they are going to present in front of the class allows them to take ownership and want accuracy.