154: Combating Stage Fright in Dementia Care with Adria Thompson MA, CCC-SLP

And welcome to the first one. Speech Uncensored Podcast. I'm Leanne. I'm your host, and I'm joined today by Adria Thompson, a returnee to the podcast. Adria, I'm so happy to have you back. I am so happy to be back. I was really excited when you asked. Oh, oh yes. It yes, absolutely. Like I'm so happy to have you back. You have such a good topic.

Um your wheelhouse is basically like anything dementia. So literally you could, as I just told you, you could come on here and talk about anything under the sun in your wheelhouse and us SLPs would just be so delighted to hear it. Um, I thoroughly enjoyed your conversation on our previous episode. And we actually both were invited to the Missouri State uh Association conference. And so I got to jump in and he

Part of your talk while there and again, like I'm just like, this is so good. Adrian, you know obviously, you know exactly what we need and you know how to deliver the tools to help us be effective speech and language pathologists working with Um people with dementia in our skilled nursing facilities or even family members. Like if we have family members, like it's just so good. This is amazing.

Thanks. Yeah, no, I love talking about everything dementia. So any topic, any question you have, I'm here for it. Perfect. Um, I'm also really impressed by your very robust Um social media presence. Like you're just like a dedication to everyday posting boggles my mind. And so I'm just like, surely the well must run dry. No.

You are so good at providing again valuable little nuggets, like just drops of gold. All the time it's a it's very impressive and deeply appreciated. You are well beloved in our circle. Thanks. I was talking to um Rinky, you know, the speech therapist, uh that's the ad I guess administrator of the medical SLP forum and we're doing an Instagram live.

about hydration and I've been talking all about hydration on my Instagram and I was telling her how I'm gonna be posting videos. I think I had like twenty four videos like prepared for that topic and she's like How can you have more than two? Like what are you gonna talk about? I'm like, just trust me, I've got some stuff and planned. So

Yeah, no, it's it's really fun. It's a great way to be creative in like the kind of things that we do as speech therapists. And uh no, the well has not run dry yet. And I mean that is to me that is so our field. Like it is so broad and so deep. Like you can plumb the depths and there will be more.

Absolutely. And my other favorite thing about today is your title for our episode, Combating Stage Fright and Dementia Care. Uh that really resonated with me because like It's not a population I've had a ton of exposure to in my outpatient setting. Um, and so if I got somebody on my caseload, I would have a moment of panic where I'd be like, ooh, what am I going to do here? What what certain what what can I do? And so that's what today's talk is all about.

Yeah. Um so without further ado, I just need to hand it over to the professional. Um so Adria, tell us a little bit about yourself, um, who you are, where you are, what you do, and then let's dive into our topic. Yeah. So my name's Adria Thompson. I'm a speech language pathologist, uh dementia educator, and I own my own business, B Light Care Consulting. I've been at SLP for nine years. And um most of my experience has been in long term care, memory care, assisted living.

And with my business, Be Like Care, I now create social media content daily uh for two hundred and seventy five thousand followers at this point. Uh but I also do a lot of dementia consulting, working with companies and brands that want to be more dementia friendly. So that's a great honor. And yeah, I'm in Kentucky right now, uh, right outside of Cincinnati at the moment, but I move around a lot. So that's

I think last time we talked I was in Washington. So yeah, you just never know where I'll be. Where Adrian's gonna pop up. Missouri State Conference Association. Like who knows? Love it.

All right. Um, okay. So uh you know, the age old question, should SLPs work with people with dementia? Like it's a progressive neurological disease. Oh, insurance we we can't track improvement, they're not getting better, so what role do we have here? Short answer yes, SLP should work with people with dementia. And it is very common for

Phrases to be thrown around like someone with dementia is not appropriate for therapy or they're not a good candidate for skilled intervention. I saw that recently on a Facebook. page on an SLP forum that they're too progressed, like they're they're not gonna get better. Although um I would love everyone to raise their right hand and promise to never say those statements ever again, I understand why they are said and I maybe have been

guilty of saying that early in my career. But individuals with dementia absolutely can benefit from our skilled services. There the difference here is the expected approach and what the actual approach that we're taking with therapy. When someone is getting therapy, often we consider it and we even call it rehab, rehabilitation. And my husband, for example, broke his foot and he had surgery just three days ago. And so he is going to participate in rehabilitation physical therapy.

And what that looks like is we look at the abilities and skills he had before, which was he loved to run, he loved to play basketball, he would go to the climbing gym, super active and wood hike, you know, all of those things. But then there was an illness, injury, injury. Condition, an event that happened, which was him breaking his foot and subsequent surgery. And on the other side of that event, we our goal in rehabilitation is to restore and recover the skills that he lost.

So he will not be fully rehabbed until he can run and play basketball and hike and all of those things. That would be rehabilitation. And when we think about Speech therapy in that lens of rehabilitation. And it is what we do a lot of times for individuals of with various conditions.

then it is perfectly understandable that people are confused as to why a speech therapist could be beneficial in someone with dementia because we can't recover or restore the abilities that they had before the event of dementia. And so when we think of it as a rehab, yes, there absolutely will be confusion. But the thing we often miss is that there's another approach called habilitation that is equally important. It is also skilled service. It's also reimbursed by insurance.

Habilitation says yes, there are abilities that exist. then there is an event that happens. But on the other side of that, instead of recovering and restoring those abilities, what we want to do is maximize and maintain the skills they have now. And that is what we do with individuals with dementia and what we do with individuals with any type of degenerative condition. Parkinson's, ALS, Huntington's disease.

But for some reason it's often more understandable that a speech therapist has a role in someone maybe with ALS than with dementia. And I'm not really sure. Why that is. I'm so glad you pointed that out. Yeah, you're absolutely right. As soon as you said that, I was like We don't tell people with ALS, Oh, I'm sorry, you have a progressive neurological situation. Um

Yeah, I have to step out. Like I only do rehabilitation. Like, no, we partner with them. We prolong independence as uh we maximize the skills that are intact as long as they are. We provide education and support to meet each stage as the disease progresses. But yet we look at our people with dementia and we're like, Yeah. Yeah, that's too bad. You know, you have dementia, so there's really nothing we can do.

I'm so glad you pointed that out. It is it's absolutely true. And like the approach is the same. Habilitation. We wanna maximize and maintain independence, safety, quality of life, comfort, whatever that might be. And so that is the approach that we as speech therapists need to take with individuals with dementia. We're not curing anything, we're not preventing anything.

And they will decline, but that's the nature of the disease, and it's understandable. And too often we take the symptoms of dementia. And we make those the reasons why they shouldn't get therapy rather than the symptoms being the things that we are focusing on and and compensating for.

So we say, Oh, well they're combative, so they're not appropriate for therapy Or they can't follow directions, so they're not a good candidate. But they're not running for president. We we're we're trying to get them to take a shower, you know? Like Yeah, I mean we we are

we look at the symptoms of dementia, that the things that are happening because of this brain disease that they have, and we point to those and say, Well, that's why they don't need therapy. No, that's what we're that's what we're treating. So

If if we as speech language pathologists who have master's degrees and extensive education and experience and a vast understanding of communication, expressive and receptive, if we are not willing to use our skills, to support individuals with dementia and their caregivers, then who the heck will? In one sense it's stepping into a void, but in the other sense it's like that is exactly where we need to be. It's not like we're just some kind of like

you know, skilled interventionist with a savior complex. It's absolutely our work and where we sh ought to be. We're just having to cut through some of the noise that's been built up around it that's prevented us from providing our skilled services in those arenas.

Yes. And our traditional ways of approaching these things don't work. And so then we're like, oh, well then I guess there isn't anything we can do because everything I've learned, all the tools in my tool belt, they won't work with this population.

And so that's where I love your approach and how you reframe these things. And in our first conversation, you're like, why aren't we in the bathroom? And I'm like, uh, because we're not occupational therapists. Thank you, Adria. That's a very big important distinction. And then you just unpack like Well, convert like conversation. Communication doesn't stop when they enter a bathroom and that impedes ADLs. And so they have a communication deficit. That's exactly where we oughta be. Um

It's still very challenging for me to accept, which is why I love being an outpatient. Yeah, I mean it's not it's not for everybody. I mean, I heck, I am not a pediatric therapist. Please don't ever make me be one.

And so, you know, it it that's that's just, you know, we all go into our strengths, but we have to understand you know, a role to be able to advocate for our field as a whole, if not anything else, you know, and like you said at the beginning, if we are not working with people with dementia professionally, we're going to interact with someone personally.

So it's important to still have these skills and this perspective. And if you feel like your therapy if someone if you feel like someone does not fit your therapy, then make your therapy fit them. Like change, you're the one that can change. So yeah. And and so I think that there's some perspective shifting things that we can do to make us feel more relevant and effective when working with individuals with dementia and staging

is one of them. That's the the stage fright that we often feel is not understanding the stages of dementia and how that can help us guide our treatment. Excellent. Okay, so tell me more about staging. Is that something there's like one, two, three, four and we like

assess them and say they're stage this, stage that. Is that infringing on any other health professionals territory? Is that something we can document or just something for our own use as we're working with the individual? Like what's happening? Yeah, that's a great question. So broadly, determining someone's stage of dementia basically is just determining like

on the ty on the spectrum of their first symptom of dementia to the how severe it will get for them, the very last day of their life, where do they fall? Right. That's what we're looking at is How bad are they? How or how good are they? Like where are we in the general progression of this progressive disease? And so staging is just a guidance. um marker for us. It is not diagnosable. So there is no ICD 10 code for

stage five dementia. Staging is just a tool, it's a generalized tool and it's not really um medically diagnosed by any professional. What not not even like, you know, neurologists or whatever, a lot of times we'll hear many different skills. So yeah, there's many different scales that exist for talking about this progression with dementia. We will often hear early, middle, or late. or mild, moderate, or severe. That's the more subjective

um staging that we will hear. And that is often what medical professionals and what we hear in media, right? Like, oh, he has moderate dementia or early dementia. And so that's a generalized scale. There are other scales that exist, um, like the our occupational therapy colleagues will often use the Allen cognitive levels. That is a one through six scale.

Teepa Snow is an occupational therapist who has a lot of dementia training and does a lot of certifications and she uses a gems model and gems in the fact of like she'll describe people like an emerald, a pearl, a ruby. And so um that exists, that's a variabilities-based model.

But the staging that we can talk about today specifically is called the global deterioration scale. And that is a scale developed by Dr. Barry Risberg in the 1980s, and it is one of the most well-known and most referenced. Scales that exist that describe stages of dementia from one to seven. So there's a it's a seven-point scale. So yeah, to answer your question, like that's what we use to give general guidelines, any of those stages, but it's not necessarily something that is diagnosable.

And we will can get into this a little bit later, but in documentation, when I do reference a stage, I will say patient's cognitive ability is characteristic of stage. five dementia, for example. So we can say that in a way that's like their cognitive abilities reflect this stage that exists. not I have diagnosed them with this certain state.

Okay. Um I can give you a little overview of them if that would be helpful. Always. Okay. So my caveat to saying these stages of dementia number one is that um there's no specific timeline that someone's gonna stay in a stage. Someone may be in a stage for two weeks, they might be there for five years. Um it's you'll you can Google it and you can find averages, but for most caregivers I say, you know, don't really

bother because uh your loved one will be individualized. It's gonna change basically, but mostly changes um because of other medical conditions. So if someone is in a stage and they undergo surgery, anesthesia, maybe they have a hip fracture, maybe they have a heart attack or a stroke or um an infection, they can progress more quickly to a stage Than they would have otherwise if they had been healthy. So there's no set timeline. Nobody fits perfectly in a stage, and that's because.

Someone doesn't go to sleep one stage and wake up the next. It is a slow progression over time. And so um we will see when we're describing these stages that people will seem to fit into a stage four and then maybe also stage five, but also stage six kind of seems like them. That's completely normal. And the third caveat here is that the the global deterioration scale and most stages that exist. more most closely reflects the change that happens with Alzheimer's disease.

There are many different types of dementia. Alzheimer's is the most common, but it's also the most slowly progressive. and the most predictable, to be honest. So um other types of dementia like Lewy body dementia, frontemporal dementia, Huntington's disease, Korzakov syndrome, those all progress a little bit differently. They start differently, they progress differently, they look different.

So we can use the global deterioration scale on some of these other scales to give a general uh overview of where someone might be, even if they have those other stages of dementia, but it's always really important that we provide education that they're not going to fit as well. So with those things said, the global deterioration scale is a scale from one to seven, one being normal cognition, no changes, no problems.

Seven being the most severe or end stage and everything in between. So stage two would be considered age-associated memory impairment. That's where you start noticing changes in yourself. but other people don't notice. That is what should be expected for aging. Beyond that, it's not normal.

Stage three is mild cognitive impairment. That is where other people start to notice, but you're impaired you're not being impaired to the point where you are impacting your everyday life. You're not having trouble actually caring for yourself. Stage four is mild dementia. This is when it is starting to impair your ability to live your normal life and daily activities. we see a lot of denial, um, or what we might call anasygnosia more appropriately.

at this point and people at this point also will um either react sometimes in anger or frustration or they might withdraw or isolate themselves because they have some awareness of the changes that are happening, but they don't have a full understanding Of its impact. Stage five is considered moderate dementia. This is where someone can no longer survive without assistance. They need supervision. And um so we see deficits in memory and communication.

that are gonna be really ramping up at this point. Communication, not only their ability to express themselves, but their ability to understand others. And because they're struggling expressing their needs and also understanding what we want them to do. We will see some sundowning uh

Behaviors, if you will. I hate that word, but you know. Um, and that's just simply because they don't always understand what we're asking them to do. And Much like the cognitive uh the spoon theory that you referenced at a um your presentation in Missouri, um this is b basically the understanding that uh as you have a neurological condition It takes more cognitive energy to do everyday tasks.

And so individuals with dementia will run out of cognitive energy earlier in the day, and that's what looks like sundowning. Stage six is moderately severe dementia, and this is where context Uh begins to become less relevant. So their environment is not communicating things to them as often and as clearly. So if I were to take off all of my clothes in my bathroom with the door locked, I would feel pretty comfortable with that.

But if I was standing on a stage in front of people presenting, I would not feel comfortable taking all my clothes off. And so um much like our environment, impacts our ability to feel safe in certain situations or not safe in others. People at this stage of dementia don't have that context and they can't know when moments are safe or not. And so we see some more resistance, aggression, kind of behavior looking things. Um communication is just really not functional at this point.

And then stage seven is severe dementia. This is end stage. This is where someone has to be cared for twenty four seven. They have to be turned every two hours. They have to be fed. They can no longer walk. And they can vocalize and maybe talk some, but it's it's not gonna be uh anything really of relevance. So those are the seven stages of dementia. Not everybody goes through all the stages because sometimes other medical conditions will end someone's life before they get all the way through.

Uh but for someone with Alzheimer's disease it can take up to twenty years to get through all of those stages of dementia, which is a really long time. And so that's why it's important to know that dementia is not just something that it's like, oh, get your affairs in order. Your life is going to end soon. No, they're living for a long time with dementia and therefore we need to be involved.

Mm-hmm. Okay. That's a lot. I'm sorry. No, that was wonderful. When you talked about um when you described sundowning as like they have just used up their cognitive energy for the day. And so that's what that looks like. That just like you know, opened up my brain to so much like that makes so much sense to me that like Yeah, that was a beautiful simple illustration of like What that is, what's happening? Why

why we have that term sundowning and not sunrising. You know, why this is happening in the afternoon and the evening and Like what that means, that just makes they're just exhausted. Their brain stopped working. That happens to me on a much, you know, lower level. But like I get that. Like Absolutely. I mean, on those days that we like especially like when um

days I have to like present or or do something that's super cognitively taxing, you can forget it the rest of the day. Like, I am not going to be helpful, I am not gonna be kind, probably either,'cause I'm just left with so little, you know. Uh and and I think yeah, it it is a really good way to kind of understand what sundowning is. There's a lot of different theories, but I think that's really the one that encompasses what everybody's trying to say. Yeah, yeah.

Um, okay, so you've described the the staging to us and we're like, okay, you know, I understand it. I feel like I can fit somebody you know in this. What do we do with that information? How does that affect our interactions and the skilled services we

I will say that was a super quick uh description. There are many uh uh descriptions of those stages, especially when it comes to function, like what they can physically do and how they can physically take care of themselves, which is also important for us to know. just for context,'cause we're not occupational therapists, but we do need to just see the full picture.

And so I encourage anyone who wants to know more about staging to pursue a CEU about that or you know just even at the very least go to my Instagram and watch all my videos. I have a s I have a video about every stage of dementia and describe it. in 60 to 90 seconds. Um so there's a lot more information that is beyond what I just rattled off uh from memory. But We need to know these stages of dementia because uh i w in the habilitation.

approach, we need to understand that we're not going to be working backwards. When we see someone in a stage, we need to accept that that's where they are. And so as a speech therapist, it's important for us to be able to determine with some level of clarity or authority, um, what stage that they're in so that we know where to work from, so that we can guide our treatment, our goal writing, our documentation to reflect the reality of the situation.

So as a speech therapist, something that we can do to help us determine the stage of dementia, there's a few assessments. The um FLCI, the functional linguistic communication inventory, uh, I think that's more for moderate to severe individuals. Um can result in a global deterioration scale stage.

the Arizona Battery for Communication Cognitive Communication Disorders, the ABCD, is for someone maybe in earlier stages of dementia, and that results in a global deterioration scale. But the t assessment that is the quickest And that was also made by Dr. Barry Risberg, who created the global deterioration skill. The assessment that goes along with that is called the brief cognitive rating skill. I'll refer to it as the BCRS moving forward, just for clarity's sake.

But the BCRS is something that we can administer as speech therapists, and it is super conversational. It is very non confrontational, which I think is important for someone with a cognitive impairment, especially someone who might not be aware that they have a cognitive impairment. They might have anazygnosia, being unaware of their deficit.

And um so it is my favorite test to give. And Leanne, if you're down for it, I'd like to administer it to you right now. Um only slightly scared about what the results might be, but let's do it. Um so for anyone listening, the brief cognitive rating scale and the global deterioration scale is is free online. So that's also what makes it awesome. You can Google it and find a PDF and just use it right away. There's no certification you need or any kind of special training.

Um, but sometimes it can be a little uh intimidating. to know how what this looks like. So I want you to listen to me as I give this to Leanne and Leanne, you can answer honestly or you can give yourself a cognitive impairment. I will not be scoring you at the end, but I just want to give an example of what the conversation might sound like. that gives us all the information that we need to be able to stage someone. Cause I think listeners will be um surprised how easy it is to give.

Action. Okay. Hi, my name is Adria. What's your name? I'm Leanne. Leanne, really nice to meet you. Where are you from, Leanne? Tallahassee. Tallahassee, you know actually, I think I think my aunt is from Tallahassee, believe it or not. What uh what elementary school did you go to by chance? I think you guys are around the same age.

Sable Palm. Sable Palm. Okay, I'm gonna write that down and see if that's maybe where she went. Can you remember any of your teachers' names? I'd love to see if she maybe had the same teachers. Probably remember all of them. Probably just like maybe one or two. One or two. Let's go with Miss Morrison. Miss Morrison? Can you think of another? Maybe Miss McIntyre?

Okay, Miss Macinth. I'm gonna ask my aunt and see if she went there and if she had those same teachers. Wouldn't that be crazy? That would be such a s yeah, that would be wild. What's your aunt's name? Oh, her name is Sharon. Um, so yeah, I'll I'll let you know next time I see you. You know, speaking of school, what was your favorite subject? Thank you. Uh, the playground time. Oh, playgrounds? Yeah, that was really fun. You know, I'm kind of a nerd, but my favorite was math.

Are you any good at math? No. Don't don't like that one. Oh, you don't like math. You know, but I bet you're better at math than you think you are. Okay. I'm gonna prove it to you. Let's test it, all right? What is what's 100 minus seven? 93. 93? See, there you go. Okay, what's 93 minus seven? Oh no, now you have the big questions. Lord. See, I will fail my own assessment. Okay. You know what? Actually, that was that was too hard. That was kind of mean of me. What is 40 minus 4?

Thirty six? Thirty six, yeah. And what's thirty six minus four? 32. So you still got it, Leanne? You can do math. Great. Yeah. I know, yeah, I know. That was kinda silly. Let's get back to some things that you might actually enjoy talking about. What do you Can you tell me a little bit about like what brought you here? Like why, what, what's been your last few days like? Well, they they brought me here, they keep me here.

I know. It can be it's hard. Change can be really hard. Do you like this place? I don't dislike it. Okay, fair enough. Is there anything that you've found that you enjoyed? Well, do you like TV, for example? I watch a little bit of the television. Yeah. You know, I do I like watching TV, but I feel like lately every time I've turned on the TV, like they're talking about the president. Like every time his face is like the first thing I see. It have you noticed that?

I have. Yeah. I just I would hate to to be him and have to have my face everywhere. Oh seems like a really big job. Yeah. Leanne, you're gonna you're gonna be so Okay, I'm embarrassed, but can you what what's the president's name? I cannot think of it. Oh my gosh, what's his name? Let's go with Joe Biden. Joe Biden. Oh my gosh. I'm so embarrassed. You're right. That's right. Oh my gosh. Joe Biden. Okay.

Um, so anyway, the reason I came here today, I just wanted to check on you and see how things are doing. And I'm gonna make a few notes just to make sure everything's going well. Let me write some stuff down. Do you know the date today by chance? Is it July? It's Thursday. It it yeah, that's okay. Thursday. July what, do you know? July seventeenth. Okay. All right, thank you Alright, so cut. Alright, so that's it. Alright, thank you for going along with that, Leanne.

But that I with that conversation I have everything I need to determine what stage of dementia you're in. And it felt, although kind of silly at times, it wouldn't necessarily feel confrontational, wouldn't feel like that moment where you're sitting down with the slums or the mini mental where you're like, Okay, I'm gonna give you five words. Can you repeat them for me? Right? Like it felt more natural. You might have thought I was a weirdo for like kind of going down paths making you say,

um making you do calculations. But honestly, that is the same script I've used for every patient I've had in the past several years. And it's worked every time to give me all the information I need.

Does that do does that feel doable? Yeah, it does. And it doesn't feel like it really ruins any potential for rapport. Um And you can, I mean, obviously in a real setting, we can just like work in other conversations in there, but for the purpose of the podcast and for for clarity's sake, I wanna uh just kind of get down to the questions I would ask. But that is for someone.

Especially in the mild to moderate range of dementia, like that's going to feel much safer and they're likely gonna perform at their best level when you're assessing them. in a conversational way rather than putting them on the on, you know, like trying to nail down all these different kind of things that we always usually ask them to do.

Um, so if you look at the brief brief cognitive reading skill, you will um see that I asked you p questions about past memory, where are you from? Do you know your teachers' names? What elementary school did you go to? I asked you calculation questions, which is for concentration. That's the first section. There's okay, let me back up. There's five areas of the brief cognitive rating scale.

concentration, past memory, recent memory, orientation, and self-care. And so I asked you questions about your past. I had you concentrate with those calculations. I asked you about recent events, like what brought you here. It's to see if you're oriented to know who the president is and then ask you the date.

I asked you the date in a very, you know, uh you can't see me on the podcast, but you know, I have like a notebook and I'm like writing something down. How many times through our day, especially when I would be working, I'd be like, what's the date today? You know, you ask people that.

But if you do it in a way that's just like, ugh, what's the date? Rather than do you know what month it is? Do you know what year it is? It just feels better for both. And yes, you can build and maintain that rapport. So the last section is functioning and self-care. And that information we can obtain by from caregivers. That just says can they shower on their own? Can they go to the bathroom? Can they do like functional things?

Uh quickly there is another assessment called the FAST, the functional assessment of staging tool. And that is also the same guy, Dr. Barry Risberg, created it. And it is um just taking that last axis, that last section on the brief cognitive rating scale. and breaking it down further and an assessment all on its own. Um so That's the very basic information I can give you about staging that would be

Relevant for a short podcast like this. There's a lot more to it, but the brief cognitive rating skill is absolutely something that speech therapists need to be aware of when we want to stage. And I guess, you know, the next relevant uh topic would be why is it important, right? Yeah. Yeah. Why d why do we do that? Why do we need to know? What are we gonna well and once we know, what do we do with that information? Yeah.

So like I said, kind of uh introducing this is that We need to know the stage of dementia so we know where we're working from. We're not gonna be if someone's in stage five, we don't need to have expectations that we're gonna get them to a stage four again. This is a degenerative disease, and we need to just think about what abilities do they have in this moment and what's cognitively appropriate for them and how can we maximize their skills.

So what we can do with this information is write goals that are appropriate. So for someone who is in stage five, six, and seven. Because in the definition of stage five, someone requires supervision to survive. We shouldn't be writing goals that require them to be independent in things that are important. So we shouldn't be writing goals for medication administration, for independence, for 90% accuracy independently, right?

That's not in line with their stage of dementia, and that's not cognitively appropriate for them to be able to do. We shouldn't be writing orientation goals for them to be able to attend activities on their own by referencing a calendar and navigating to the activity room when someone's in stage six.

because their context doesn't give them information. They don't even know what room they're in right now, much less that there's an activity room down the hall, much less what day it is and time it is and all of those kind of things. So helping us know what stage of dementia we're in can help us know what expectations we should have for goals. It's important to know that it's okay to write a goal for 50% accuracy if they're at 20% accuracy.

We always, I always learned 80% accuracy, 90% of opportunities, right? Like all of those like super successful every single time they are going to be perfect. It's okay to write goals for someone in the later stages of dementia when the accuracy is not always spot on. It's okay to write goals. I like the phrase, um, with cues from trained caregivers.

Because that reflects the fact that we're not necessarily training the person, the patient. We are training the caregivers to provide proper cueing. So phrases like with cues from trained caregivers is a great little segment to put in any goal. Patient will attend activities 80% of opportunities with cues from trained caregivers.

If activities is important for that person with dementia to go to and they don't have the cognitive ability, reflective of the stage of dementia they're in, we don't need to be putting it on their shoulders to be able to get there. We need to be training the the the staff. And not only um coming in and getting them, but the proper communication techniques that are gonna maximize their compliance with those instructions.

So other phrases I really like in goal writing for people with dementia is cognitively appropriate communication strategies. So Patient will consume um 90%, or if we're talking about like mealtime, patient will consume. Seventy-five percent of meals with cues from trained caregivers using cognitively appropriate communication strategies.

That's reflecting that the work we're doing isn't necessarily directly with the patient. It's not direct treatment. It's indirect treatment. We're directly treating the caregivers and training them in what to do.

So uh it's knowing the stage can help us know accuracy of goals. It can also help us determine frequency and duration that we need to be treating our individuals with dementia. If someone is in the very early stages and stage four, maybe they're even in mild cognitive impairment, stage three, they're highly motivated. and they can actively participate in sessions, it might be perfectly appropriate in the skilled nursing

setting to treat them five days a week for an hour and a half, potentially, if they can do that. But for someone in stage six, that would never be appropriate. If they can't attend or remember for more than 10 seconds, good luck. treating them for ninety minutes five times a week, you know. So knowing their stage is going to be able to give us the power to advocate for this the therapy they need and also the therapy they don't need.

Because we all have been in situations where maybe a therapy company or some other entity has pressured us to do something that we don't think is appropriate. If we have that stage of dementia, we can better communicate not only what they need, but what they don't need and why. So I think that's like it's empowering. It gives us a lot of information uh to to make them do the things that are actually going to be useful to them. Yeah. I love that.

That's really helpful. I feel yeah. You really I mean that was your plan all along, but like I'm finally cluing into it that staging um the person with dementia Helps everything. Like literally everything. Everything. It helps us understand like the level of support, supervision, assistance, like

Everything. It helps us know because there's so many times that caregivers will come to me and be like, you know, even just like things like, Oh, well mom used to be able to take her incontinence product off and put it in the trash can, but now she's keeping it on or she's putting it over her pants or And like how do I help her remember how to do that?

And unfortunately, we also get to the point where we're like, okay, you know, that was maybe when she was in stage four. But at this point, it looks as though her cognitive abilities are reflective of someone in stage five or stage six. And so it's no longer cognitively appropriate for her to be able to do that on her own. We are now at the point where she's needing more supervision, she's needing more hands-on care. We ha it allows us also, like I said, to draw the line of like

It's it's not that we need to find the right technique to get her to be independent. It's that maybe she no longer can be. And we just have to up the level of care. We have to up the level of supervision. And that is hard, but having the stages help us communicate that and help caregivers, whether it's someone at home or a CNA at a nursing home, understand that difference.

I feel completely enlightened. Like this is really, really helpful for knowing like which direction to go when you're presented, you know, with the I mean it's what we go asking for. Like what do you want help with? You know, how can we improve functionality, quality of life? And so they're like, well they could they could do this, now they can't.

And so in one sense, I'm waiting for you to be like, okay, well here's the special fix for that. But you're like, well, that's just not the level that they're at. They need the increase.

supervision and assistance. That's where they're at cognitively. And so that's the result of that. And there's not like a special bullet. So Can you give me some examples that you've experienced in working with the stages and working with patients and or family members like the caregivers, like what that looks like in practice and really? So an example of someone who had mild cognitive impairment. She actually had cognitive deficit secondary to multiple sclerosis. We'll call her Anne.

you know, when I assessed her, I saw what her abilities were, what her deficits were. And she was someone who was really motivated. After she understood what kind of services I could provide her, she was really motivated. And so determining what we want to target for someone with a cognitive impairment.

Um it's always asking those questions like you said, w what's important to you? How can we help you? I like the question, um, what do you find frustrating? Or, you know, I I'm here to make your life easier. I'm a problem solver. Is there anything I can do to help you? Sometimes we get too bogged down on like I'm a speech language pathologist. I help people in communication, swallowing, and cognition. Are there any things in that area that I can help you with?

it's easier just to say, What's frustrating? What can I help you with? And then we determine if that's if we have a role in that. Because sometimes it's, well, my T V's broken. And we might assume Oh, we need to call the maintenance ban, but really we need to pick up the remote and realize that the TV's not broken. They just don't know how to use it anymore. There's our role.

So for s for Anne, her biggest thing she wanted was um that was gonna make the most difference in her quality of life. This is when I was working in Washington. She wanted to memorize the numbers and players of the Seattle Seahawks football team. like the major like starters. She wanted to w know when she'cause she couldn't see their names on their jerseys or like she didn't know ways there was new people. So we spent time Uh memorizing the names with every

number of the football team. And that was cognitively appropriate for her. That was because she has mild mild cognitive impairment, she still has those skills and we can use them and compensate. We made some external memory aids and signs. some reminders, we used association, all of these memory techniques that was appropriate for her. And so because I knew that after assessing her, we ran with that.

And we'll talk about um William. He was someone who was in a memory care community. He was scoring late stage six. Specifically, he had a big impairment in language. Um he had Alzheimer's disease, but that just it was his language deficit seemed to be uh more significant than other people at his same stage and same condition. And so we had the issue where if he looked down and he had been incontinent and he could see that his pants were wet.

He would be motivated and agreeable to going to the bathroom and taking them off. However, if he was sitting in the moment of being incontinent, and there was any leakage or wetness on the back of his pants and he couldn't visually see it when he looked down. he didn't know that he needed to do that. And so getting him changed at that point was much more difficult. He was what we might call combative, because we're trying to take off his pants and he doesn't understand why.

And so I knew from his staging that we are never going to convince him. We're not going to be able to explain to him in a way that he's going to finally understand and agree that he needs to take off his pants. And so I use the thought process of in what situation is he agreeable to taking his pants off?

And I know two times that he is agreeable when he visually sees that they're wet in the front. And the second is if he puts on pants that are too tight. He hates tight pants, so he takes them off immediately. So my communication strategy to him was not verbal, but it was visual.

So when he would have moments where we would need to change his pants, we had two techniques, either of getting a wet washcloth and going over and wiping his hands and then strategically but seemingly accidentally kind of dropping the wet washcloth in his lap and leaving a wet spot. That cued him enough that communicated to him to know that he needs to change his pants. And so as soon as that would happen, oh, I'm so sorry, let's go change your pants. And he would.

So that is communication. We don't learn that in school necessarily, the wet washcloth trick. But that is the way that I knew that I could communicate with him in a cognitively appropriate based on his skills and his abilities and deficits. And then the second was um when he would stand at the toilet and he would urinate. Um Sometimes it like if we were around, we would kind of come in.

and pinch the back of his pants so that when he goes to button them they felt too tight. And so that would make that would be a cue for him to willingly take them off when they needed to be taken off. And that was in the mornings when he was getting ready. And we the compliance was so much better. There was no combativeness when we used these what we call communication techniques, even even though they don't always seem that way. Mm-hmm. And the third, um, l Lily we'll call her.

She would be resistive to changing her clothes. And she this these are all like very person centered approaches too. Like we could have a whole podcast about person centered approaches, but understanding the reality from their world and what's important to them and knowing how they tick and how they value like what their values are and So Lily was a very like proud person. She was always really fancy and dressed really nice. And so in the mornings when we would get her dressed,

Um she would never want to wear anything. No. She hated it, everything she just didn't like. And so knowing what we knew about her and we we developed a way to communicate with her in a way that really touched her and met her where she was at. And that is basically taking her clothes that she has had for years. and putting them in a gift bag or putting them in a shopping bag, and then presenting them to her as though they were new.

And she would have that moment of excitedness. Oh my gosh, I got something new. She would open it up. She didn't recognize that they were something that belonged to her already. And so it was every morning she got this gift and it was fun. And we would always say, oh, let's try them on and see if they fit. Of course they fit. They're her clothes. But to her, she was trying on something new, and it was something that was like exciting for her and cognitively appropriate.

So we're not fighting where they are, but we're understanding where there are and we're doing what's cognitively appropriate. for that stage and entering their reality. Dementia care is so much fun. I just I think it's like the most creative. I've ever been is working with individuals with dementia.

I I love that because I feel like we can get bogged down or I feel like I don't know like the The word on the street is like, ooh, it's just hard because yes, oh, there's these behaviors. You have to fight through the behaviors. You have to convince them. And you're like, let's get creative. let's find alternative pathways of communication that meet them where they're at because our traditional

you know, word vomiting is not gonna meet them where they're at. Their their brains can't handle that at the stage that they may be in. What's another way we can communicate the same thing? And so if we're like hungering to use creativity in our skill sets, like this sounds like a great population to use them with. It is a lot of problem solving, a lot of creativity.

And I love the passion that you bring to that and the excitement. Like I think that can like really speak to a lot of people and kind of revive their interest in the work that we do. Absolutely. It's it's a blast and it's such an honor too. Like it's super gives you a lot of purpose in this setting. So I love it. Yeah, that's awesome. Um, Adria, is there anything else um that you want to share with us? Did we cover everything? Yeah, I think

I think we did. I mean, there's a lot of co like caveat conversations we could have about every aspect of this, which I would be glad to come on again and do. Um, but when it comes to staging, I just encourage SLPs to just start trying. Um, I think often I had the the perspective that I didn't know enough or like I didn't really like understand all the stages, I hadn't memorized them, so therefore I shouldn't like even try. Um but I really encourage you to just

start us doing this assessment at the brief cognitive rating scale. You hear, you heard me. It's simple. Um But just start trying. And the more that you engage with individuals with dementia and guess, I always try to guess their stage and then do an assessment and try to confirm it. And um that really helps that.

interrater um, you know, accuracy there. And so um it just with practice, just like anything, you'll get better and just try. It's all trial and error with dementia, but sometimes also trial and error with ourselves. and figuring some things out. Excellent. That's awesome. Well, Adria, if people are interested in following up with you or reaching out and contacting you, how can they go about doing that? You can find me on Instagram, Facebook, and TikTok at B LightCare.

And um I like I said I have videos about all of these things. I have tons of posts and really practical, it's really important for me to provide practical tips. for caregivers and um you know, as speech therapists for caregivers. I d I never called myself that before. I got in this specialty. Um, but we care for people and um it's it's can be really life-giving. So reach out to me and those.

um social media aspects but also my email is info at be light care. I do caregiver consultations but also SLP consultations as well. So you can read about that at be lightcare.com. Awesome. And we'll have those links in our show notes on speechandsensor.com and we'll list out the assessments that you talked about, some of those uh staging recommendations that you reviewed. Um and anything else that you wanna put in our resource list for our listeners, I think that'd be great. Sounds great.

Well thank you again, Adria. This is always a pleasure. Always a pleasure. It was a lot of fun. Thanks for having me. No problem. And for our listeners, I hope that this episode has nourished your brain so that you can go out and flourish in your practice and be awesome.