The Memory Unit OT

So remember when we talked about the anatomical and physiological changes in the brain that limit direction following in individuals living with dementia? Let’s talk about how we can therapeutically intervene in this area.

There are 3 basic types of cues that therapists can provide: verbal, visual, and tactile. When we routinely combine these 3 types of cues into one direction or command, we can refer to it as a multi-sensory approach.

As always, when we’re considering our residents and patients who are living with dementia, it’s important to consider the ‘why’ behind the behavior or deficit or need that we are noticing.

Can they hear me? How stimulated and busy is the environment? Do they want to do the thing that I’m asking them to do? Do they feel safe? Do they remember enough about their immediate context to follow the direction I’m giving?

Let’s look at a practical example.

I’m giving my resident a direction: “We’re going to walk to the community room”. And I’m giving this direction because it’s time for Bingo, I know they love Bingo, and I’m working on maximizing active and meaningful engagement in the community routine. But if my patient doesn’t know what time or day it is, they might not understand why I’m asking them to do this, they might not want to follow that direction, and they might feel distressed if they don’t remember in that moment where the community room is.

In this example, giving context around a direction might achieve a better response. So instead of saying “We’re going to walk to the community room” I might say “Bingo starts in five minutes, let’s walk together to the community room”. This little bit of added context might meet some of those unmet needs we just considered, thereby eliciting a better outcome.

Now I think the typical ‘next step’ so to say when someone is exhibiting difficulty following just a verbal cue (even with the additional context) is to add a visual component. This could be a written statement, a single written word, or even a picture.

If you Google ‘clipart of sitting’ or ‘clipart of eating lunch’ right now, you’re gonna find lots of cartoon kids with smiling faces sitting on a little stool or carpet square or in a school cafeteria. And yeah that works as an added visual image to a verbal cue….

…but let’s amp this up a little bit.

Let’s take actual photos of our residents doing actual things in their actual environments.

The best SLP I’ve ever worked with once made an entire picture book of a resident’s functional routine. She took photos of his bedroom, his bathroom, his walker, him engaged in exercise class and craft activities and music groups, him sitting the dining room eating lunch, even a photo of his wife. She printed each photo out on it’s own individual page, adding a single word or phrase underneath. This photo book was integrated into all therapy sessions across all disciplines, and was then transferred to the nursing staff to continue to use after therapy discharge.

Visual cues can also look like task modeling, meaning you model the behavior that you’re asking the person to perform.

So when I say “Brush your teeth” I mimic that same motion with my hand. Or when I say “Stand up” I gesture an upward motion with my entire body to demonstrate what I’m asking this person to do. I can then add in a tactile cue by gently pushing forward on the upper back or grabbing their hand as if to help them stand up.

There are literally so many ways that we can combine all three types of cues in order to improve direction following; the above are just a few examples. And I want you to always remember that neural plasticity is a thing (even in some instances of dementia). Thinking back to that patient who used the photo book I described earlier, with repetition of this technique he actually got to a point where he only needed the visual cue 50% of the time. The other 50% of the time he could understand and follow a single verbal cue. So don’t be afraid to work towards improved verbal language comprehension, even knowing that eventually that skill may dissolve entirely as the disease progresses.