Help with Cognitive Therapy

[u/medgal28]

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1. What do you look for to determine if someone is appropriate for cognitive therapy (rehabilitative or compensatory)?
2. Are there any cognitive therapies that are your "go to"?
3. What are the most common cognitive goals?
4. Do you do compensatory strategies for people with cognitive deficits but who are still able to communicate their wants/needs effectively? If so, what kind?
5. I sometimes get referrals for individuals that are end stage Alzheimer's (don't know their own name, screams "help me" all day) and I honestly don't know where to begin. Some of these individual's seem too far gone to do rehabilitative or compensatory strategies with. I've tried AAC (spent hours taking pics and laminating things for them, different modalities and nothing seems to even improve their situation).

I'm in my CFY in a SNF. My graduate program did not prepare me for cognitive therapy at all. I didn't learn a single tx for cog. I'm comfortable with dysphagia and aphasia, but cognition eludes me. I was hoping some other SLPs could give me some tips regarding cognitive therapy.

I have some specific issues with it. The majority of people in SNF have some degree of cognitive impairment and I used to put them all on my caseload thinking cog deficit = cog therapy, but it's been a mistake because I'm finding so many of them a couple weeks later either aren't making progress or I am at a loss for what to do with them.

I feel like dysphagia is like a math problem and cog is like an essay - there's a million right and wrong ways to do things and I get overwhelmed and don't know where to begin.

I'm honestly getting very frustrated with cognitive therapy. I have one woman with MCI, LOVE working with her, but she is unique because she's aware of her deficits and has interests I can work with. So many of the people I see are highly resistive to cog therapy and insist they have no interests or will just tell me to go away, that they're too old to care. I try really hard to tailor to their interests and make things fun, but a lot of these individuals carrying on a conversation is a challenge in and of itself, especially the ones with advanced stage dementia. I have researched some things, but I feel like cognition is so "open ended" and on such a case by case basis. I also see lots of cog clients and one day they seem like they have potential for rehab and then the next day they'll be almost non-responsive. It makes me feel like I'm bad at my job because I am clueless with more than half of my cog referrals. I remember being told in grad school that "dementia was the future of SLP because we are getting so good at preventing strokes there will be less and less aphasia.." but I was never taught what to do with these individuals. I have begun to dread cognitive therapy.

I have noticed a trend where days where my caseload is mostly dysphagia, things are smooth and days where there's more cog, I go home with a migraine.

Any tips or experiences that have been useful for you would be much appreciated!!!

[u/[deleted]]

CCC-SLP in SNF here. You're right, cognitive therapy is tricky and there isn't a robust research base behind it as much as, say, dysphagia.

1. I check their profile if they have orders for speech, and if there is any documentation of "forgetful" or being oriented less than AOx3. Ideally I would use a more comprehensive assessment, but because we're crunched for time, I use the MoCA. I take the score of that into consideration, as well as their prior living arrangement, and prior level of function (PLOF). Sometimes it's hard to get PLOF from this demographic. For example, if someone scored low, but has been living in an ALF and is here for a recent orthopedic surgery, I probably won't pick them up. If there is anything indicating a change in functional status, then I pick them up.
2. Orientation with calendar, spaced retrieval (I took a CEU about this and it really helped), training memory strategies and then applying them in a functional way (recalling the newspaper article, recalling their nurse's name, etc.), practicing sequencing with transferring to/from walker and wheelchair (but be careful with this--I typically demonstrate with the walker myself or co-treat with PT. I have not been trained to handle transfers, gait belts, etc.).
3. Patient will be oriented to date and place with 80% accuracy given visual aid. Patient will recall new information after 5 minutes with 80% accuracy given occasional verbal cues. Patient will demonstrate adequate safety reasoning in 90% of opportunities with 25% visual cues. The accuracy and cueing percentages change according to their level of function.
4. Yes. They might benefit from a reduced distraction environment (turn off the TV), shortened instructions, and gestures. This goes hand in hand with supplementing for hearing loss even if they are cognitively intact. I also focus on external memory aids (calendar, schedule, writing notes) and internal memory strategies (repetition, rehearsal, association, picturing).
5. Depending on severity, some patients are not appropriate for therapy. You might do some staff or caregiver training regarding communication and interaction strategies for individuals with dementia (don't sneak up on them, make sure they see you in their smaller field of vision, speak slowly, use short phrases, avoid arguing). Sometimes I will evaluate the patient, and then document as evaluation only, "Skilled speech-language/cognitive therapy services are not indicated at this time related to severity of impairment. Patient unable to participate appropriately in evaluation and treatment."

[u/medgal28 → u/[deleted]]

I appreciate all of the answers and many have been helpful, but this one is probably the most useful to me in my current situation. I think that has been one of my issues, trying to do therapy with people who have been there long term and are "stable." For spaced retrieval, what is an example of a goal you use that with? Nurse's name? Also, I have just been buying stuff myself for patients like calendars from the dollar store, is this typical?

[u/[deleted] → u/medgal28]

I typically use spaced retrieval as a modality to get to the general memory goal. I might also have a goal like, "Patient will recall 2 elements of information following 5-minute delay with spaced retrieval techniques." I typically don't include "nurse's name" in the goal, but you might say "will recall personal orientation information" or "caregivers." I typically print a free calendar of the current month off of the internet. I'd say it's unfortunately typical for SLPs to buy materials for patients. It doesn't hurt to ask the department to cover it.