ASHA - 2020 - Dementia - Practice Portal
ASHA - 2020 - Dementia - Practice Portal
Overview
See the Dementia Evidence Map for summaries of the available research on this topic.
Alzheimer's disease,
Lewy body disease,
vascular pathology (e.g., multi-infarct dementia),
frontotemporal lobar degeneration (e.g., Pick's disease and primary progressive
aphasia),
Huntington's disease,
Parkinson's disease.
Other conditions that result in dementia due to progressive changes in brain function
include
(Albert et al., 2011; American Psychiatric Association [AMA], 2013; Bourgeois &
Hickey, 2009; Key-DeLyria, 2013; Mahendra & Hopper, 2013)
Early Onset
Dementia is typically associated with the elderly population. However, dementia can
affect younger individuals. Early-onset dementia (EOD) refers to dementias that occur
before the age of 65.
Differential diagnosis of EOD is complicated by the fact that symptoms may be more
variable in younger patients than in the elderly, due to different etiologies (McMurtray,
Clark, Christine, & Mendez., 2006; Fadil et al., 2009) and a lack of awareness about
the condition, even among health care professionals (Jefferies & Agrawal, 2009). In
addition, some causes of EOD are curable, which makes the need for timely and
accurate diagnosis even more crucial (Fadil et al., 2009).
The needs of younger individuals with dementia are different from those of individuals
with late-onset dementia. EOD often affects individuals who are working and have
dependent families and significant financial responsibilities, and services and supports
for these individuals are complex and require input from a multidisciplinary team
(Jefferies & Agrawal, 2009). Early diagnosis allows for early treatment, access to
appropriate supports, and long-term preparation and planning for the family.
Attention
Common attention deficits include
Perceptual Abilities
Common perceptual deficits include
Language
Common language deficits include
Causes
Cognitive Reserve
Most dementias are the result of neuropathology resulting from diffuse degeneration in
cortical and/or subcortical structures and neural pathways, and/or chemical
changes that affect neural functioning. Examples of structural changes include
neurofibrillary tangles and neuritic plaques, commonly associated with Alzheimer's
disease. Neural pathways (connections between neurons) responsible for memory and
new learning are also lost. Examples of chemical changes include cholinergic deficits
within the subcortical structures, as in Alzheimer's disease, or chemical imbalances
associated with metabolic disorders.
Alzheimer's disease is the most common cause of dementia, accounting for
approximately 70% of all cases (Plassman et al., 2007), and the risk of acquiring
Alzheimer's is higher if an individual has a first-order relative with the disease
(Lovestone, 1999). Vascular dementia is widely considered the second most common
cause, accounting for approximately 17% (Plassman et al., 2007). The remaining
cases are accounted for by dementia with Lewy bodies, Parkinson's disease,
frontotemporal lobar dementia, and mixed dementia types (e.g., AD with Lewy body
pathology and AD with vascular pathology; Mahendra & Hopper, 2013; Plassman et
al., 2007).
Cognitive Reserve
The concept of cognitive reserve was introduced to account for the observation that
there does not appear to be a direct relationship between the severity of brain damage
or pathology and the degree of disruption in performance (Stern, 2003, 2009). It is
applicable to most situations in which disruption to brain functioning occurs, including
traumatic brain injury and dementia.
Models of cognitive reserve postulate that increased brain reserve capacity (e.g., brain
size or synapse count; Satz, 1993) or more efficient cognitive processing (Stern, 2002)
allows some individuals to cope with brain insult better than others. Individual
differences in cognitive reserve can stem from genetic differences or differences in life
experiences, including educational and occupational experiences and involvement in
leisure activities (Stern, 2009).
In addition to lifestyle factors, lifelong bilingualism has been proposed as a factor
contributing to cognitive reserve. In studies comparing bilingual and monolingual
individuals, bilinguals demonstrated onset of dementia symptoms approximately 4 to 5
years later than monolinguals (Bialystok, Craik, & Freedman, 2007; Craik, Bialystok, &
Freedman, 2010). The cognitive demands of bilingualism may contribute to an
increased cognitive reserve in much the same way as other stimulating activities (Craik
et al., 2010). These results cannot be generalized to individuals who are not fully
bilingual (Bialystok et al., 2007).
Interprofessional Collaboration
identifying risk factors for dementia, taking into account variability among
individuals from different racial and ethnic backgrounds and culturally and
linguistically diverse populations;
providing prevention information to individuals and groups known to be at risk
for dementia, as well as to individuals working with those at risk;
educating other professionals, third-party payers, and legislators on the needs
of persons with dementia and the role of SLPs in diagnosing and managing
cognitive communication and swallowing disorders associated with dementia;
educating caregivers about possible communication difficulties and providing
strategies to facilitate effective communication;
screening individuals who present with language and communication
difficulties, including hearing screening;
determining the need for further assessment and/or referral for other services;
conducting a culturally and linguistically appropriate comprehensive
assessment across the SLP scope of practice, including assessment of
cognitive-communication functioning and swallowing;
diagnosing cognitive-communication disorders of dementia across the course
of the underlying disease complex;
assessing, diagnosing, and treating swallowing disorders associated with
dementia;
referring to an audiologist to rule out hearing loss and balance problems;
referring to other professionals to rule out other conditions, determine etiology,
and facilitate access to comprehensive services;
making decisions about the management of cognitive-communication deficits
associated with dementia;
developing treatment plans for maintaining cognitive-communication and
functional abilities at the highest level throughout the underlying disease
course;
treating the cognitive aspects of communication, including attention, memory,
sequencing, problem solving, and executive functioning;
selecting culturally and linguistically appropriate techniques for direct
intervention;
gathering and reporting treatment outcomes;
monitoring cognitive-communicative status to ensure appropriate intervention
and support;
providing indirect intervention through the individual's caregivers and
environmental modification;
providing counseling to persons with dementia and their families regarding
communication-related issues and providing information about the nature of
dementia and its course;
consulting and collaborating with other professionals, family members,
caregivers, and others to facilitate program development and to provide
supervision, evaluation, and/or expert testimony, as appropriate;
remaining informed of research in the area of dementia and helping advance
the knowledge base related to the nature and treatment of dementia;
advocating for individuals with dementia and their families at the local, state,
and national levels;
serving as an integral member of an interdisciplinary team working with
individuals with dementia and their families/caregivers;
serving as a case manager, coordinator, or team leader to ensure appropriate
and timely delivery of a comprehensive management plan;
providing quality control and risk management.
As indicated in the Code of Ethics, SLPs who serve this population should be
specifically educated and appropriately trained to do so. Given the relationship
between cognition and communication, practitioners who serve individuals with
dementia require knowledge and skills in both areas, including specific knowledge of
cognitive-communication disorders associated with dementia, to fulfill the
aforementioned roles.
Most common dementia-associated diseases are progressive in nature, and SLPs
have an ethical responsibility to provide appropriate services that will benefit the
individual and maximize cognitive-communication functioning at all stages of the
disease process.
Interprofessional Collaboration
SLPs collaborate with many other disciplines in caring for individuals with dementia.
Referral and collaboration between members of the team, particularly during the
assessment process and treatment planning, are important to help ensure quality
service for individuals affected by communication and cognitive disorders.
Coordinating assessment can prevent overlap in test selection. Ultimately, the focus of
collaborative efforts must be on the clinical utility of information and how professionals
with complementary knowledge and skills can affect functional outcomes for patients in
a beneficial manner.
Assessment
Screening
Comprehensive Assessment
See the Assessment section of the Dementia Evidence Map for pertinent scientific
evidence, expert opinion, and client/caregiver perspective.
The diagnosis of dementia is made by a medical team. The role of the speech-
language pathologist (SLP) is to assess cognitive-communication deficits related to
dementia (e.g., memory problems; disorientation to time, place, and person; difficulty
with language comprehension and expression) and to identify cultural, environmental,
and linguistic factors that impede functioning.
The SLP determines the most appropriate assessment protocol based on the stage of
dementia and the individual's communication needs. In addition, when selecting
cognitive-communication screening instruments and subsequent tests for
comprehensive evaluation, the clinician considers the cultural and linguistic
background of the client, using tests that have normative samples of culturally and
ethnically diverse groups when available. Standard scores should not be reported, if
the normative sample is not representative of the individual being assessed.
Screening
Screening for cognitive impairment is conducted by an SLP or other member of the
interdisciplinary care team for individuals with any condition that increases their risk for
cognitive-communicative problems, including hearing loss. Many standardized
instruments with demonstrated reliability for screening of dementia are available.
These instruments typically assess orientation to time, place, and person. Other tests
(e.g., story recall/story retelling) assess episodic memory and can be useful for
screening for early dementia (Bayles & Tomoeda, 1993; Rabin et al., 2009; Takayama,
2010; Wechsler, 1999).
Prior to screening for cognitive-communication disorders associated with dementia, it
is important to consider the impact of sensory impairment, depression, and current
medications on cognitive functioning. If screening reveals cognitive impairment,
individuals are referred to an SLP for a comprehensive evaluation of communicative
function. Referral for other examinations or services are made as needed.
Hearing Loss
Hearing loss is common among older adults, and many individuals have untreated
hearing loss and do not wear hearing aids or make use of other hearing technologies.
Audiometric hearing screening and otoscopic inspection for impacted cerumen are to
be conducted prior to cognitive-communication screening.
Traditional behavioral tests of hearing (e.g., pure tone and speech audiometry) are
generally successful in the early stages of dementia, although modifications such as
simplifying directions, using pulse tones, slowing presentation of speech stimuli,
providing reminders to respond, and responding with "yes" instead of raising a finger
or pressing a button may be needed. During the later stages of dementia, more
objective tests (e.g., otoacoustic emissions or auditory steady state response) may be
necessary to obtain estimated thresholds (Burkhalter, Allen, Skaar, Crittenden, &
Burgio, 2009), as may be modifications of assessment procedures for those patients
who do not condition to standard tasks.
If the individual fails the hearing screening, a referral is made to an audiologist for a
comprehensive assessment. If an individual has a diagnosed hearing loss and wears
hearing aids, hearing aids are inspected to ensure that they are in working order and
worn by the individual during cognitive-communication screening. The use of assistive
listening technology should be employed when hearing aids are not being used.
Visual Impairment
If visual deficits are suspected, the individual is referred for vision testing prior to
completing cognitive-communication screening. Prescription eye glasses, as needed,
are to be worn during screening, and adequate lighting used in the test (and treatment)
environment.
Depression
Depression is common in individuals with dementia and can adversely affect test
performance. Cognitive changes associated with depression so resemble the cognitive
changes associated with dementia that depressive symptoms are often referred to as
"pseudodementia." If signs and symptoms of depression are present, the individual is
referred to a neuropsychologist or clinical psychologist experienced with geriatric
depression.
Medications
Prior to screening, the SLP considers the effects of prescription drugs on cognitive-
communicative function. Polypharmacy, or the concurrent use of several medications,
is common among older adults who have multiple medical conditions, and some
medications may exacerbate cognitive problems. Questions about the effects of
medication use on cognitive-communication functioning can be answered by a
pharmacist knowledgeable in geriatric pharmacy.
Comprehensive Assessment
Individuals suspected of having cognitive-communication problems are referred for a
comprehensive assessment of language and communication. SLPs often conduct
these assessments in collaboration with neuropsychologists. Assessment may include
clinical observations in the home or long-term care setting.
Assessment is conducted to identify and describe
Assessment of Swallowing
A comprehensive assessment includes a swallowing screening or, if indicated, a
swallowing assessment. An estimated 45% of individuals with dementia residing in an
institution have dysphagia (Easterling & Robbins, 2008), and dysphagia is more
prevalent in patients with Alzheimer's disease than in normal elderly individuals
(Horner, Alberts, Dawson, & Cook, 1994). This increased prevalence may be
associated with a diminished sense of smell and cognitive changes associated with the
progression of dementia (Easterling & Robbins, 2008).
Swallowing assessment with individuals with dementia involves evaluation of
Assessment Measures
There are a number of assessment tools that produce a valid characterization of
cognitive-communication strengths and weaknesses—including language
comprehension and expression and integrity of working, declarative, and procedural
memory systems—and that have been standardized on individuals with dementia. The
severity level of dementia in the individual being tested is factored into test selection.
Some tests are too difficult for the individual with severe dementia and do not yield
useful information, because the individual fails most or all of the items.
Treatment
See the Treatment section of the Dementia Evidence Map for pertinent scientific
evidence, expert opinion, and client/caregiver perspective.
Treatment Options
The goal of cognitive-communication treatment is to maximize the individual's quality
of life and communication success, using whichever approach or combination of
approaches meets the needs and values of that individual.
The following are brief descriptions of both general and specific treatments for persons
with cognitive-communication disorders associated with dementia. Some treatment
approaches are considered compensatory, and some are considered restorative in
nature. Compensatory treatment approaches focus on teaching methods and skills to
compensate for or overcome deficits that are not amenable to retraining. Restorative
treatments involve direct therapy aimed at improving or restoring impaired function(s)
through retraining. Where available, links to evidence and expert opinion regarding the
intervention are provided. This list is not exhaustive nor does inclusion of any specific
treatment approach imply endorsement by ASHA.
Environmental Modifications
Environmental modifications are changes or adaptations to the environment to improve
communication skills in individuals with dementia. Modifications are aimed at
optimizing the cognitive, visual, and auditory aspects of the environment and include
improving lighting, reducing glare, and reducing visual clutter; minimizing background
noise and noise reverberation; and providing cues (e.g., signs that incorporate text and
simple graphics) and displaying personal items to improve memory, awareness, and
orientation (Brush, Sanford, Fleder, Bruce, & Calkins, 2011).
Memory-Training Programs
Memory-training programs focus on improving/re-training memory skills using
techniques such as spaced retrieval, errorless learning, procedural memory
stimulation, vanishing cues, and didactic approaches.
Montessori-Based Treatment
Montessori-based treatments use principles developed by Maria Montessori (2008),
including using real-life materials, designing activities that are of interest to the
individual, allowing learning to progress in sequence, minimizing the risk of failure and
maximizing the chance of success, and breaking down activities into component parts
and practicing these one at a time.
Validation Therapy
Validation therapy is an approach that involves validating or accepting the values,
beliefs, and reality of the person with dementia to help reduce stress and provide
opportunities for the individual to communicate his or her feelings; validation therapy
was developed by Naomi Feil (1982) for individuals with cognitive impairment and
dementia.
Diet Modifications
Diet modifications consist of altering the viscosity, texture, temperature, or taste of a
food or liquid to facilitate safety and ease of swallowing. Typical modifications may
include thickening liquids (e.g., water, coffee, juice) or softening, chopping, or pureeing
solid foods. Taste or temperature of a food may be altered to provide additional
sensory input for swallowing, and preferences of the individual are considered to the
extent feasible. The nutritional needs of the individual and the safety of medical
treatments (e.g., swallowing vitamin supplements or drinking thin liquids) are also
considered before making modifications. A referral to a dietician is made as necessary.
Postural Changes
Positioning techniques involve adjusting an individual's posture or position during
feeding. These techniques aim to protect the airway and offer safe transit of food and
liquid. No single posture will provide improvement to all patients/clients; rather, the
general goal is to establish central alignment and stability for safe feeding.
Tube Feeding
Tube feeding includes supplemental or alternative avenues of intake (e.g., nasogastric
tube [NG], transpyloric tube placed in the duodenum or jejunum, or gastrostomy-G-
tube placed into the stomach or GJ-tube placed into the jejunum). These approaches
may be used if the individual's swallowing safety and efficiency cannot reach a level of
adequate function or does not support nutrition and hydration adequately. In these
instances, the swallowing and feeding team considers whether the individual will need
the supplemental or alternative source for a short or extended period of time to
determine the optimum tube feeding selection to best meet the individual's needs.
Alternative feeding does not preclude the need for feeding-related treatment.
End-of-Life Issues
Speech-language pathologists (SLPs) working with individuals with dementia may be
presented with a patient nearing the end of life. These patients introduce complex
clinical and ethical issues around feeding and communication that impact the role of
the SLP and other health care professionals.
The goal of intervention with patients at this stage is not rehabilitative, but facilitative or
palliative. The SLP may be asked to participate in team decision making regarding the
use of alternative nutrition, such as tube feeding (Landes, 1999), and may develop an
alternative communication strategy, if appropriate, that will allow the individual to
express his or her wants and needs more effectively. The expected outcome of
intervention is not necessarily to improve abilities, but to allow the individual to use the
abilities he or she still possesses to interact with family and friends and/or enjoy
favorite foods, if that is the patient's wish.
The pattern of functional decline in individuals at the end of life varies, depending on a
person's diagnosis. In dementia, the decline may be inconsistent over a long period of
time. SLPs need to understand the process of dying to understand the emotional and
psychological issues faced by their patients and patients' family members. The wishes
of the patient and family are paramount when considering end-of-life issues, and the
role of the SLP extends only as far as the patient or family wishes. What the SLP may
think is best for the patient clinically may not always be accepted as best for the
patient's quality of life. The document, 2004-2005 Ethics, Rights, and Responsibilities
Standards of the Joint Commission on Accreditation of Healthcare Organizations,
addresses this issue in Standard RI.2.80.
Views of the natural aging process and acceptance of disability vary by culture.
Cultural views and preferences may not be consistent with medical approaches
typically used in the U.S. health care system, but must be recognized and respected.
The clinician approaches clinical interactions with cultural humility and demonstrates
sensitivity to social and cultural influences when sharing potential treatment
recommendations and outcomes. See end-of-life issues in speech-language
pathology (ASHA, n.d.).
Service Delivery
See the Service Delivery section of the Dementia Evidence Map for pertinent scientific
evidence, expert opinion, and client/caregiver perspective.
In addition to determining the type of treatment that is optimal for the person with
dementia, the clinician considers other service delivery variables that may have an
impact on treatment outcomes, such as