Dementia and Treatment as it Applies to Speech Language Pathology

Etiology

The term dementia refers to an umbrella term that describes conditions that affect several aspects of cognition due to neurons in the brain (Alzheimer’s Association, 2014). Specifically, dementia refers to a progressive condition in which a variety of symptoms exist, including: memory loss, expressive language impairments, impaired communication, ability to reason, mood, and personality (Alzheimer’s Society, 2013). It is a major health concern for the population affected (Fredriksen-Goldsen, Jen, Bryan & Goldsen, 2018). Alzheimer’s is the most commonly seen type of dementia, with the estimation of prevalence being 5.4 million Americans (Alzheimer’s Association, 2016). Globally, the estimated prevalence is 35.6 million, with the population of patients expected to double every 20 years (Prince et al., 2013). Currently, there is no cure for dementia (Livingston and Frankish, 2015).

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The focal types of dementia include Alzheimer’s, which becomes more severe over time, and Lewy body dementia that is commonly associated with Parkinson’s disease and which may cause the patient to suffer from vivid hallucinations. Sleep disturbances are also characteristic of dementia (Walker et al, 2015). In 2016, it was estimated that 236 billion dollars was spent on treatment and care for patients that suffered from Alzheimer’s disease and other dementias. This makes Alzheimer’s disease and other dementias the most expensive diseases in America (Alzheimer’s Association, 2016). There are several neurobehavioral and language characteristics that are associated with dementia.

Neurobehavioral and language characteristics

Each type of dementia presents with varying degrees of communication deficits. These deficits can be in the areas of expressive or receptive language, voice fluency, or the social use of language, which is referred to as pragmatics. These deficits can advance to a point in which the patient loses all functional communication abilities (Woodard, 2013). This can negatively impact the patient’s quality of life and escalate the burden that caregivers often undertake. Responsive behaviors such as violent behavior, foul language, and repetitive questioning may be a result of the frustration caused from losing the ability to functionally communicate (Savundranayagam, Hummert, & Montgomery, 2005). As the dementia progresses in severity, these responsive behaviors can increase. Treatment from a speech-language pathologist can prove very beneficial in treatment for dementia patients.

Treatment as it applies to the field of speech/language pathology

 Intervention conducted by a speech-language pathologist may enrich function communication abilities of a person with dementia. Speech-language pathologists play a vital role in functional communication treatment as dementia progresses (Alzheimer’s Association, 2014). It has been reported by speech-language pathologists that the knowledge they possess to aid in treatment of patients with dementia is underutilized. Other health professions do not recognize the wealth of knowledge that a speech-language pathologist possesses (Swan et al., 2018). It is up to the professionals of speech-language pathology to utilize evidence based practice and provide sufficient data that supports functional communication growth following treatment by a speech-language pathologist.

 It is important to take into consideration the patient’s wants, needs, abilities, strengths, and level of support care when the subject of treatment is discussed. It is just as important to realize that treatment for mild-moderate dementia will vary from treatment for severe dementia. The appropriateness and effectives of intervention approaches should be analyzed before treatment begins (Swan et al., 2018).

Intervention approaches have been recently classified as cognitive training, cognitive rehabilitation, and cognitive stimulation. Cognitive training utilizes a restorative strategy; cognitive rehabilitation utilizes a mixture of restorative and compensatory strategies; while cognitive stimulation utilizes interventions that provide gratifying stimulants that promote socialization and a feeling of enjoyment (Swan et al., 2018). Several studies have been conducted that delve into treatment approaches provided by a speech-language pathologist for patients with dementia. Positive outcomes have been reported using cognitive training, cognitive rehabilitation, and cognitive stimulation approaches (Swan et al., 2018).

Frattali (2004) conducted a study that utilized a cognitive training approach of individual naming therapy. An errorless naming approach to naming was employed. The goal of the study was to improve naming of semantic categories using a conversational approach. Word retrieval tasks were influenced to create errorless learning. Forty picture card stimuli were organized according to categories. The treatment was comprised of 12 sessions, divided into two phases. The first phase consisted of noun training and generalization to untrained verbs. The second phase consisted of noun training, generalization to untrained verbs, and maintenance of performance for previously taught verbs. Conversational exchange was employed to discuss the semantic properties of each card.

The results of this study were very similar to other studies of this nature. They imply that the benefits gained from this study were largely due to the naturalistic, conversational approach of the treatment sessions. The nature of exchanges between the patient and clinician were natural and evenly divided among participation. Additionally, pragmatic exchanges made between the patient and clinician were evenly divided in participation, and allowed for naturalistic, rather than clinically structured communication exchanges (Frattali, 2004).

Overall, gains were made in vocabulary skills and quality of life in patients with dementia. Though, despite gains made during active treatment periods, at a follow up assessment three months after the initial intervention took place, all skills had been lost. This implies that for the knowledge gained during treatment to remain in working knowledge, treatment has to be ongoing (Frattali, 2004).

In a study conducted by Spector, Thorgrimsen, Woods, Royan, Davies, Butterworth, and Orrell (2003), the hypothesis of using cognitive stimulation therapy would reap benefits for geriatric patients with dementia. A single-blind, randomized selection and intervention process was utilized. One hundred fifteen patients participated, of which, 89 were of the control group. Fourteen sessions of interventions designed using cognitive stimulation took place. Topics of the sessions included money, famous familiar faces, and word retrieval games. The sessions included a “reality orientation board.” The purpose of the board was to remind participants of the nature of their work. A small group session was found to be beneficial for participants. The intimate, close-knit environment allowed the participants to exercise communication skills that have not been utilized in quite some time (Spector, et al., 2003).

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Sessions were focused on themes that allowed the participants to reminisce, but still be reminded of present-day topics, such as childhood and food. Sessions encouraged the participants to process information rather than recite from long-term memory. The Mini–Mental State Examination, a test of cognitive function, was utilized as a primary measure to assess cognition. Various secondary measures, such as quality of life, communication, behavior, global functioning, depression, and anxiety were utilized as well. The study found that participants showed significant growth in both cognition and quality of life. No changes in behavior were noted, though there were positive trends noted in the area of communication (Spector, et al., 2003).

In a recent systematic review of speech-language pathologist interventions for communication in moderate to severe dementia patients conducted by Swan, Hopper, Wenke, Jackson, Till, and Conway, 2018, evidence for direct and indirect services was analyzed. Direct intervention referred to interventions that were face to face with the person with dementia, while indirect intervention referred to interventions that addressed activities related to communication. Some inclusion criteria included communication interventions provided by a speech-language pathologist, outcome measures based on overall communication efficacy, and participants with a diagnosis of moderate-severe dementia. The studies included had to meet all of these criterion to be included in the study.

Interventions were conducted in a variety of settings, with both direct and indirect modes of treatment. The vast majority of direct intervention services were conducted via cognitive stimulation approaches. All of the studies included in the systematic review concluded with improvements in overall communication efficacy for the patients with dementia. Those with language impairments showed improvements via cognitive stimulation group treatments. Individual naming therapy via cognitive training approach showed communication increases as well. Efficacy was measured through assessment of communication skills via language and communication subtests of various cognitive tests (Swan et al., 2018).

The vast majority of indirect services were conducted via communication partner training. The mean words per topic used by the person with dementia were increased, as well as reduction in the number of topic needed to fulfill a 15 minute conversation with the trained communication partner. Conclusively, although the studies reviewed varied in settings and modalities, all studies reported a positive outcome of speech-language pathologist provided treatment in cases of those with moderate-severe dementia. Though results revealed progress in the studies reviewed, follow up evaluations yielded loss of skills (Swan et al., 2018). This further indicates that interventions must be on-going to be truly effective.

This review provided evidence that overall, the quality of life and communication of a patient with dementia can be positively affected by direct and indirect meaningful communication interventions (Swan et al., 2018). Patients with dementia deserve the best quality of life possible. A key factor in preserving quality of life is communication. Communication skills can help to allow the patient to have their wants and needs met, along with the basic need of humanity, functional relationships.

Conclusion

In conclusion, dementia refers to a progressive condition in which a variety of symptoms exist, including: memory loss, expressive language impairments, impaired communication, ability to reason, mood, and personality (Alzheimer’s Society, 2013). Speech language pathologists play an essential role in treatment of dementia. It is essential to communicate, support, and advocate for patients who suffer from dementia (Butcher, 2018.)

 Intervention approaches include cognitive training, cognitive rehabilitation, and cognitive stimulation (Swan et al., 2018). These three intervention approaches have proven efficient in improving communication skills and quality of life for patients with dementia. Currently, though, there is no cure for dementia (Livingston and Frankish, 2015), these interventions help patients with dementia to preserve the necessary skills to retain functional communication abilities and quality of life.

References

• Alzheimer’s Association. (2014). 2014 Alzheimer’s disease facts and figures. Alzheimer’s and Dementia, 10(2), e47–e92.
• Alzheimer’s Association. (2016). Alzheimer’s disease facts and figures. Alzheimer’s & Dementia, 12(4). Retrieved from http://www.alz.org/documents_ custom/2016-facts-and- figures.pdf https://tinyurl.com/y89ujjr7
• Butcher, L. (2018). Caring for patients with dementia in the acute care setting. British Journal of Nursing, 27(7), 358–362. https://doiorg.ezproxylocal.library.nova.edu/10.12968/bjon.2018.27.7.358
• Fredriksen-Goldsen, K. I., Jen, S., Bryan, A. E. B., & Goldsen, J. (2018). Cognitive Impairment, Alzheimer’s Disease, and Other Dementias in the Lives of Lesbian, Gay, Bisexual and Transgender (LGBT) Older Adults and Their Caregivers: Needs and Competencies. Journal of Applied Gerontology, 37(5), 545–569. https://doi- org.ezproxylocal.library.nova.edu/10.1177/0733464816672047
• Frattali, C. (2004). An errorless learning approach to treating dysnomia in frontotemporal dementia. Journal of Medical Speech-Language Pathology, 12(3), xi–xxiv.
• Livingston, G., Frankish, H. (2015). A global perspective on dementia care: A lancet commission. Lancet. 386(9997): 933–4. https://doi.org/10.1016/ S0140-6736(15)00078-1
• Prince, M., Bryce, R., Albanese, E., Wimo, A., Ribeiro, W., & Ferri, C. P. (2013). The global prevalence of dementia: A systematic review and met analysis. Alzheimer’s and Dementia, 9(1), 63–75. e62.
• Savundranayagam, M. Y., Hummert, M. L., & Montgomery, R. J. (2005). Investigating the effects of communication problems on caregiver burden. Journals of Gerontology: Series B: Psychological Sciences and Social Sciences, 60(1), S48–S55.
• Spector, A., Thorgrimsen, L., Woods, B., Royan, L., Davies, S., Butterworth, M., & Orrell, M. (2003). Efficacy of an evidence-based cognitive stimulation therapy program for people with dementia. The British Journal of Psychiatry, Aug 183(3), 248–254. https://doi.org/10.1192/bjp.183.3.248
• Swan, K., Hopper, M., Wenke, R., Jackson, C., Till, T., & Conway, E. (2018). Speech-Language               Pathologist Interventions for Communication in Moderate-Severe Dementia: A Systematic Review. American Journal of Speech-Language Pathology, 27(2), 836–852. https://doi-org.ezproxylocal.library.nova.edu/10.1044/2017pass:[_]AJSLP-17-0043
• Walker, Z., Possin, K.L., Boeve, B.F., Aarsland D. (2015). Lewy body dementias. Lancet. 386(10004): 1683–97. https://doi.org/10.1016/S0140-6736 (15)00462-6
• Woodward, M. (2013). Aspects of communication in Alzheimer’s disease: Clinical features and treatment options. International Psychogeriatrics, 25(6), 877–885