Dementia Flashcards
what is dementia
Dementia is a clinical syndrome characterised by a progressive loss of cognitive ability, ultimately resulting in a loss of functional independence (WHO, 2017). It can affect memory, thinking, orientation, comprehension, calculation, learning capacity, language and judgement (WHO, 2017). The DSM- V (American Psychiatric Association [APA], 2013) Dementia diagnostic criteria state that a diagnosis may be reached if there is evidence from the client’s history and a clinical assessment which indicate significant cognitive impairment in at least one of the following domains: learning and memory, language, complex attention, perceptual-motor function and social cognition. The impairment must be acquired and progressive and represent a significant decline from previous level of functioning. Additionally, the disturbances must not occur exclusively during the course of delirium. Dementia currently affects about 64,000 people in Ireland (HSE, 2020).
alzheimer’s disease
Alzheimer’s Disease is a slowly progressive degenerative disorder in which memory loss is the hallmark symptom (Bourgeois & Hickey, 2009). It occurs as a result of changes in the temporal and parietal lobes associated with the presence of amyloid plaques. It is the most common cause of dementia and can be diagnosed with a lumbar puncture to examine cerebrospinal fluid for atypical amyloid levels, or through an MRI or PET scan of the brain. Client’s with Alzheimer’s Disease demonstrate a specific communication profile. They are initially very fluent with no articulation, phonological or syntax errors and reading, writing and pragmatics remain relatively intact, although these can become more impaired in time. They will usually have lexical-semantic issues, which begins with issues accessing semantic and lexical information (presenting as word-finding difficulties), and eventually progresses to impaired abilities to learn new vocabulary. Later there will be a difficulty in comprehension of complex information, and reduced verbal fluency (phonological fluency will be better than semantic fluency). Social conversation is a strength in the mild to moderate stages - it remains relatively unimpaired. As the disease progresses reducing semantic access, however, discourse becomes empty and there is an increased reliance on automatic phrases. The client will find it difficult to pay attention to their communication partner and there will be difficulties with turn-taking and topic maintenance. In later stages, communication can become severely impaired.
vascular dementia
Vascular dementia is caused by stroke or cerebrovascular disorders. This results in sudden dementia onset with fluctuations. Due to the nature of the cause there may be additional difficulties depending on the area of atrophy such as aphasia, dysarthria, or other cognitive communication difficulties including reduced insight, apathy, delayed processing, reduced attention (Bourgeois & Hickey, 2009).
Lewy Body Dementia
Lewy Body Dementia is caused by small proteins called Lewy Bodies that deposit in the neuronal cell bodies in the frontal and temporal lobes and the basal ganglia, interfering with acetylcholine and dopamine effects on the brain. Presentation of LBD is a very distinctive pattern of fluctuating cognitive, psychiatric and motor symptoms. Many people will also present with Parkinsonism such as rigidity, bradykinesia, tremor and gait changes. Many people present with dual pathology of AD and LBD. LBD has a particular cognitive communication presentation which includes: symptoms of Parkinsonism in speech: (flat affect, dysphonia, hypophonia); word finding difficulties; and hallucination content may disrupt conversation.
Dementia in Parkinson’s
Dementia develops in approximately 18-30% of people with Parkinson’s Disease. This type of dementia is characterised by reduced memory. People with PD can demonstrate pragmatic difficulties like processing emotional meaning. Parkinson’s dementia usually presents with more fluctuations and slower processing speeds than AD. PD dementia usually presents with more executive functioning difficulties than language impairments.
Dementia in progressive supranuclear palsy
Dementia in Progressive Supranuclear Palsy is characterised by primarily executive impairments. There is frontal lobe dysfunction, which makes people present as apathetic and disinhibited due to poor self monitoring. Additionally, they may present with delayed processing and reduced memory.
Dementia in Huntington’s
Huntington‘s Disease is a hereditary progressive neurodegenerative disorder of the basal ganglia. It causes general cognitive decline including dementia. The physical and emotional deficits caused by the disease have impacts on communication competence. Some cognitive communication difficulties associated with dementia of this type include deficits in attention, memory, problem solving, and perceiving and interpreting facial expressions. The person may also experience difficulties with conversation management, including decreased initiation of conversation, diminished topic maintenance, impact on discourse structure and coherence, and difficulties comprehending abstract concepts.
Dementia in ID
Between 15 and 45% of people with Down Syndrome over the age of 40 years suffer from Alzheimer’s type dementia. There are some extra considerations for assessment and care of this cohort. They will function cognitively and emotionally at an earlier developmental stage and therefore, the commonly used standardised assessments may not be appropriate for them. Additionally, many health care professionals have little experience and education in dealing effectively with people with ID. For this client group, changes in overall function, personality and behavior may be more common early signs of dementia than memory loss and forgetfulness. (Alzheimer’s Association, 2015). People with ID often have pre-existing communication difficulties and lack the ability to self-report feelings or difficulties.
Frontotemporal dementia
Frontotemporal Dementia is a type of dementia resulting from progressive atrophy in the frontal and temporal brain regions. It has a younger onset - usually 50s/60s. This dementia can cause personality and behavioural changes. Impaired social cognition is one of its hallmark features. People with this type of dementia experience significant difficulties attending to and engaging with a conversational partner which usually stems from a reduced interest in the environment and distractibility. They also experience difficulties in responding correctly in conversation, difficulty organising discourse, poor self monitoring, turn-taking and topic maintenance as well as disordered prosody.
PPA
Primary progressive Aphasia is a group of three subtypes of progressive language impairment associated with frontotemporal degeneration. It refers to a clinical presentation, not a pathological cause. According to Gorno-Tempini (2011), in order to be diagnosed with PPA language processes must be affected first in the absence of significant cognitive difficulties, there must be no focal lesion which could have caused the language problem and onset must be insidious and progressive.
Subtypes of ppa
- nonfluent
- semantic
- logopenic
Nonfluent ppa
The first type of PPA is the non-fluent type. To be diagnosed with this the person must present with either agrammatism in speech or effortful, halting speech with inconsistent speech sound errors and distortions; and at least two of the following: impaired comprehension of syntactically complex sentences, spared single word knowledge, spared object knowledge.
Semantic variant PPA
The second type of PPA is semantic variant PPA. In order to reach a diagnosis of this, the person must have impaired confrontation naming and impaired single word comprehension; and at least three of the following: impaired object knowledge, surface dyslexia or dysgraphia, spared repetition, and spared speech production in terms of motor speech and grammar.
logopenic ppa
The final type of PPA is logopenic variant PPA. In order to be diagnosed with this the person must have impaired single word retrieval in spontaneous speech and naming, and impaired repetition of sentences and phrases; and at least three of the following: speech errors in spontaneous speech and naming, spared single word comprehension and object knowledge, sparted motor speech and absence of agrammatism.
diagnosis of dementia
Dementia is assessed at three different levels: level one is assessment in primary care, level two is assessment in memory and support services, and level three is assessment in a regional specialist memory clinic. Dementia can be diagnosed by GPs, consultant geriatricians, neurologists, psychiatrists and memory clinics. These memory clinics involve an MDT who include: consultants, advanced nurse practitioners, SLTs, OTs, physios, neuropsychologists and dieticians, medical social workers and more. When a person is being assessed for dementia, there will be a discussion of their case at an MDT meeting, following this meeting they may be referred to more specialists (such as OT, physio, or SLT) for assessment, sent for further physiological assessment (such as a lumbar puncture to examine CSF for alzheimer’s disease biomarkers), or further neuroimaging (MRI, PET), once these tests have been carried out, there will be another MDT meeting to discuss the results, and a person is booked for a medical review where they may be given a diagnosis of dementia.
role of SLT
Within this MDT SLTs have a very important role. SLTs have gained recognition for their valued role in dementia care (RCSLT, 2014; IASLT, 2016). It is recommended that SLTs are involved at all stages of the person’s journey and that people should have access to pre- and post-diagnostic care (IASLT, 2016) SLTs have a key role to play in facilitating communication between the person with dementia and their family, carers and other staff in order to ensure that their personhood is promoted and that their values, will and preferences are upheld throughout the course of their condition. SLTs have a role in many different areas: identification, assessment, intervention, counselling, collaboration, case management, education, advocacy and research.
Goals of assessment
The goal of assessment is to obtain information that will help you to plan a therapy approach (Ballard et al., 2002), and as such an assessment will have multiple aims. The first of these is assessing to diagnose. This is because there are many many different types of dementia, and each type will present with different symptoms, and require different care plans, therefore a differential diagnosis is crucial to provide appropriate post-diagnostic care for the client. The second aim is to identify which areas of language the client has difficulties with, which will inform what needs to be addressed in therapy. Additionally, an assessment should show which areas of language are a strength for the client, which can then be built upon in therapy to help scaffold the difficulties. Finally, an assessment will allow the therapist to liaise with the client and their family to discover what their biggest concerns and goals are, and use this information to set intervention goals which are achievable, measurable and meaningful.
ICF
When assessing dementia, it’s important to refer to the International Classification of Functioning, Disability, and Health (ICF) (WHO, 2013). This is a framework which views health through the biopsychosocial model of disability and thus is ideal for providing client-centred care. It includes biological, individual and social perspectives of health and acknowledges the complexities of their interactions. A language assessment should take all of its domains into account: it should examine any impairments to the client’s body structures and functions; as well as activity limitations, which are difficulties an individual may have in executing activities, for example being unable to order a coffee in a coffee shop; participation restrictions, - problems an individual may experience in involvement in life situations such as being unable to participate in work or hobbies. SLTs should also examine environmental factors which are the physical, social, and attitudinal environment in which people live and conduct their lives, and any facilitators or barriers that come along with them.
case history
The first part of a communication assessment should always be taking a case history to gather information. It’s important to remember that when conducting a case history interview with a client who has a communication disorder, the client themselves may not be able to answer many questions, and sometimes recounting the circumstances surrounding the communication disorder can be very distressing. In these cases the SLT should consult the medical chart, other members of the MDT, and with consent, family members wherever possible to make sure they get the information they need with as little difficulty for the client as possible. In doing this, the SLT then only needs to ask the client the questions that nobody else can answer for them - namely their concerns about their communication and their goals for attending with the SLT. Some important aspects to inquire about in the case history include the client’s baseline speech and language function - it can be helpful to ask family members if they have any recordings of the client speaking before the onset of the communication difficulty, giving the SLT insight into what baseline was for that particular client. Overall, the case history should give the SLT information about the client’s medical, social and communication history, their environment and context, their hearing and vision, the progression of their language vs their memory difficulties, any fatigue they’re experiencing and its effects on their functioning, their first language, their level of education, their life and work experience, their physical activity level (and any barriers to physical activity), any medications or other interventions they have begun, and finally how they are coping with their diagnosis (or possibility of diagnosis), and any support systems they have in place. The case history should give the clinician some insight into all domains described by the ICF. It should also guide the clinician as to which assessment tasks will be the most appropriate to carry out.
key components of assessmetn
When assessing language and dementia there are a few key components of a language assessment. This is because different dementia types may present with very different language abilities, and a thorough assessment of the following domains can aid in reaching a differential diagnosis. These language domains include receptive language (auditory comprehension of single words, sentences and paragraphs, following commands, answering yes/no questions, semantic knowledge); expressive language (confrontational naming, generative naming, repetition of single words, simple sentences and complex sentences, picture description and narrative discourse); and finally reading and writing abilities.
formal assessment
The next step after a case history is to carry out a formal assessment. These are assessments which are standardised; the clinician administers the assessment in a predetermined manner and the client’s responses are recorded and scored according to a standardised scoring system. Their score is then converted into a standardised score which can be compared to normative data to evaluate whether the client’s language functions could be classed as aphasia. Formal assessments have advantages: they provide a significant amount of qualitative data which can then be used to inform an intervention plan and the score they provide can be used to reach a diagnosis. They are also useful for goal setting, report writing and providing objective evidence of change. However, it is important to remember that formal tests have disadvantages too: communication is context sensitive, and as formal assessments do not take this into account and therefore may not be a completely accurate reflection of the client’s abilities. It is for this reason that formal assessment tools should be used in conjunction with other assessment methods in order to gain the most accurate and complete information possible.
Barnes Language Assessment
The Barnes Language Assessment (Bryan et al, 2001), is a tool for the assessment of language and associated cognitive skills in an older population. As it is designed for an older population, it takes into account normal age-related changes in language processing in its normative data, and is a suitable screening tool for language difficulties in a person who is being assessed for dementia. Its subtests include expression (picture description, semantic and phonological fluency - animals and “s” - picture naming and word definitions), comprehension (word-picture matching and following commands), reading and writing (oral reading, spelling to dictation, sentence-writing), memory (story retell, and forward digit span) and finally executive functioning. It provides an overall profile of the client’s language skills and difficulties. The domains of language it assesses would be useful for a differential diagnosis between different types of dementia.
Functional Linguistic Communication inventory
The Functional Linguistic Communication Inventory (2nd edition) (FCI-2) (Bayles & Tomoeda, 2020) is a standardised test battery which assesses the functional language of patients who have moderate to severe dementia. Its standardisation sample includes people with vascular dementia, mixed conditions and other dementia types. It assesses ten common communication skills covering a variety of language domains: greeting and naming, answering questions, writing, comprehension of signs, object to picture matching, word reading and comprehension, reminiscing, following commands, pantomime, gesture and conversation. This assessment can be used to develop a profile of the communication strengths and weaknesses of individuals with moderate to severe dementia; predict communication functions which will become more vulnerable as the disease progresses; counsel professional and personal caregivers and finally plan functional maintenance programmes.
boston naming test
Naming refers to single-word retrieval in response to a picture or an object. One commonly used naming test is the Boston Naming Test (Goodglass et al., 2001), which assesses the client’s knowledge of nouns by asking them to identify pictures. Naming tests can be analysed to provide a significant amount of information about the client’s underlying language processing deficits. This is done by analysing their error patterns. For example, there are different types of semantic naming errors: coordinate errors - calling a chair a table, superordinate errors - calling a chair furniture, and associative errors - calling a car a tyre. Other error types include compensatory errors such as using gesture, drawing of circumlocution to get around saying the word; phonological errors which may either be whole word - calling a table a tablet - or just sound errors - calling a tablet a talet; jargon errors which is replacing a work with a nonsensical one. The SLT should notice any other behaviours such as latency and perseveration. The SLT should also make note of factors that may affect the client’s accuracy such as familiar vs unfamiliar words, nouns versus verbs, and the semantic category to which the word belongs to.
discourse analysis
Conversational or discourse analysis is an incredibly important aspect of a language assessment. This type of assessment is an analysis of recorded conversations between the client and their communication partners. It can be useful to differentiate between dementias - for example PPA (a clinical presentation of frontotemporal dementia) is characterised by significant difficulties with conversation and discourse. Additionally, it can be useful to identify areas of communication breakdown and areas of strengths. The SLT will analyse the video for conversation breakdown and repair. The SLT then reviews the video with the client and their communication partner. The conversational skills the SLT should analyse specifically are: greeting/closing, topic maintenance, tangential speech and social skills. Once the SLT has this information, they can raise awareness with both participants to their style of communication, and discuss strategies for communication breakdown and encourage use of styles which promote communication success.
In addition to this conversational analysis the client and conversation partner can also be given a questionnaire to assess their communication. One such example is the LaTrobe Communication Questionnaire (Douglas et al., 2007). This questionnaire was originally standardised for TBI patients, however the qualitative information it provides is useful in a dementia context. It measures the client’s own perception of their communicative ability, and gathers the same information from a communication partner. It is a 30 item questionnaire, given to the client and their communication partner. Each item is rated on a Likert scale: 1 = never or rarely, 2= sometimes, 3= often, 4= usually or always. The SLT can use the information gathered from this questionnaire in the same manner as information gathered from a conversational analysis.
assessment in acute care
There are additional considerations when assessing a client with dementia in an acute care setting. To begin with, they are medically unwell and are therefore unlikely to be able to participate in a long, mentally taxing communication session. Additionally, they will more than likely be participating in multiple assessments which could cause further fatigue and inability to participate fully in the assessment session. Additionally, the assessment will more than likely be a bedside assessment, meaning that the SLT will have to choose in advance which assessment tools to bring with them, and they will have limited time in which to complete the assessment. It is for this reason that in an acute care setting informal language screens, liaison with family members, consultation with the MDT and medical chart and general conversation with the client themselves are generally most appropriate. It is also important for the SLT to be aware of onward referral indicators and practices in the setting.
assessment of ppa
When assessing a client with PPA or suspected PPA there are some language domains that are crucial to assess. This is because as discussed above, there are three different subtypes of PPA and each have a very different presentation - therefore a thorough language assessment should be used to differentially diagnose the client. Further, PPA is a clinical presentation in which language impairments are the first signs of a cognitive problem, and therefore a language assessment will be the most important part of their dementia assessment so it must be incredibly thorough. It should assess cognitive linguistic abilities using formal and informal methods. Some language domains to focus assessment include comprehension at single word, sentence and paragraph level, semantics, naming, narrative, repetition and verbal fluency.
single word/sentence/paragraph comprehension
This part of assessment should assess comprehension in as many different forms as possible. Some examples of this are word/sentence to picture matching; word to definition matching; synonym matching; answering personally relevant questions; answering both simple and abstract yes/no questions; answering questions based on a read paragraph; and object knowledge. These may be assessed using informal assessment tools created by the SLT or by using formal assessment subtests such as the boston naming tests, or receptive language subtests from the WAB, BLA, and FLI-2.
semantics
The next step is to assess the person’s semantics abilities, as the second subtype of PPA affects semantics. Semantics is the representation of word meanings and concepts. It is made up of an extensive network of the associations and concepts that form our knowledge of the world. When one concept, word or event is activated, related concepts, events and words also get activated. For example, knowing a cat is an animal, and knowing it has fur and whiskers, and then, when seeing a cat, being able to attribute this knowledge to the animal you see. Essentially, it describes the ability to attach meaning to a word form, making it available to be spoken. This can be assessed using semantic subtests such as semantic fluency (naming as many objects in a category as you can in the space of a minute, or by using the pyramids and palm trees test (Howard and Patterson, 1992) - a test which uses words and pictures to assess a person’s level of access to semantic and conceptual information. It can be used to identify if the client has a central modality semantic impairment ie. the impairment persists regardless of the manner in which the information is presented.
picture description
The next step of a PPA assessment should be a picture description task (such as the Cookie Theft picture) which assesses spontaneous and connected speech. Connected speech especially is important to assess because it will reveal all underlying deficits in speech and language domains (Vermeulen, Bastinaase, and Van Wageningen, 1989).
The SLT should assess the client’s description of the picture for fluency, word-finding difficulties, effortfulness, hesitations, grammatical structure, accuracy of content, prosody, articulation, mean length of utterance, speech rate and error types.
verbal fluency
Verbal fluency is also important in PPA assessment because it can reveal defining features of both nonfluent PPA and semantic variant PPA. It is assessed using a generative naming task. This task not only assesses word retrieval but also verbal functioning which is an important cognitive-linguistic skill. Generative naming tasks usually have two components: assessment of semantic fluency and assessment of phonemic fluency. Semantic fluency resembles everyday production tasks such as making a shopping list. For this task the client is given a category such as animals and asked to name as many as they can in one minute. It examines the client’s abilities to exploit existing links between related concepts to retrieve responses. Phonemic tasks, however, require the client to think of as many words as they can in one minute beginning with a given letter. This is a more cognitively demanding task, because the words must be retrieved from a phonemic category which is rarely done in everyday speech production. The participant must suppress the activation of semantically related or associated words and resort to novel retrieval strategies. For the average person, the semantic fluency task will be much easier, however, for a person with a dementia type that affects semantic processing such as Alzheimer’s Disease or the semantic variant of PPA, the phonemic fluency task will be easier.
repetition
Repetition tasks are one way of assessing a person’s working memory, which may be affected in some dementia types, and also of differentially diagnosing the logopenic variant of PPA for which one of the defining features is poor repetition. When assessing repetition it is important to evaluate repetition of single words, multisyllabic words, phrases, sentences and non-words to determine at which level breakdown may occur.
sydney language battery
The Sydney Language Battery (Janssen et al., 2022) is a computer administered test at single word level. It assists in the diagnosis of PPA and differentiating PPA subtypes. There are 30 words within the battery across four subtests: naming, repetition, comprehension and semantic association. The items are ordered into 3 difficulty levels based on decreasing word frequency. It provides cut-off scores to detect impaired performance. Although designed for assessment and diagnosis of PPA it is not comprehensive enough to comprise a whole assessment session and should therefore be used in conjunction with other assessment tools
