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Dementia

Overview

Dementia is a syndrome resulting from acquired brain disease and characterized by progressive deterioration in memory and other cognitive domains (e.g., language, judgment, abstract thinking, and executive functioning). Although the cognitive profiles of individuals diagnosed with dementia vary somewhat by etiology, the degree of deterioration represents a decline from previous levels of functioning and is sufficient to interfere with social and occupational functioning.

The cognitive decline associated with dementia affects an individual's ability to comprehend and produce linguistic information. Additionally, behavioral problems that develop as a result of the neuropathology (e.g., paranoia, hallucinations, and repetitiousness) may interfere with communication.

The cognitive and behavioral symptoms of dementia are differentiated from those of

In contrast to these conditions, the symptoms associated with dementia continue to progress in severity until death (Bourgeois & Hickey, 2009). Neurodegenerative diseases that result in dementia include

Other conditions that result in dementia due to progressive changes in brain function include

See detailed information about common dementias.

Primary Versus Secondary Dementia

Primary dementias are those—like Alzheimer's disease (AD), multi-infarct dementia, and dementia with Lewy bodies—in which the dementia itself is the major sign of an organic brain disease not directly related to any other organic illness. Secondary dementias are those caused by, or closely related to, some other recognizable disease, such as HIV, head injury, multiple sclerosis, or chronic alcohol abuse.

Mild Cognitive Impairment

There is evidence that neuropathological changes occur well in advance of clinical manifestations of Alzheimer's dementia (Bennett et al., 2006), and subtle cognitive deficits occur up to 9 years prior to the diagnosis (Amieva et al., 2005). These and similar findings have led to the concept of mild cognitive impairment (MCI), described as a transitional stage between normal aging (i.e., age-associated memory impairment) and dementia (Bourgeois & Hickey, 2009; Qualls, 2005). Individuals diagnosed with MCI are at greater risk of developing dementia; early identification of MCI might enable the use of cognitive interventions to slow the progression of decline (Qualls, 2005).

MCI is consistent with the diagnostic category, Mild Neurocognitive Disorder, defined in the Diagnostic and Statistical Manual of Mental Disorders-5th edition (DSM-5; American Psychiatric Association, 2013). The clinical criteria for diagnosing MCI are

(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.

Relationship Between Hearing Loss and Dementia

Approximately one third of Americans between the ages of 65 and 74 and nearly half of those over the age of 75 have hearing loss (National Institute on Deafness and Other Communication Disorders [NIDCD], 2010). Many older adults will have both hearing impairment and cognitive loss, and, together, these losses will affect communication, social participation, and quality of life (Pichora-Fuller, Dupuis, Reed, & Lemke, 2013).

Lin et al. (2013) found that individuals with baseline hearing loss had greater rates of cognitive decline over time than individuals with normal hearing. Further investigation is needed to clarify this relationship and to determine whether or not hearing loss is a risk factor for dementia. One hypothesis is that when a hearing loss is present, greater cognitive resources are dedicated to auditory processing, leaving fewer resources for other cognitive processes, like working memory (Peelle, Troiani, Grossman, & Wingfield, 2011). Recent research suggests the possibility of a shared etiological pathway responsible for both hearing loss and dementia (Gallacher et al., 2012)

It is important for clinicians to differentiate between hearing loss and cognitive impairment and to identify when one or both of these conditions are present.

Incidence and Prevalence

Estimates of the prevalence of dementia vary considerably by the age group on which the estimates are based. Prevalence among those age 85 and above, for example, is likely to be considerably higher than estimates based on those age 65 and above. In addition, prevalence data are often categorized more broadly or more narrowly than "dementia." The Centers for Disease Control and Prevention, for example, cites prevalence data for specific causes of dementia, typically Alzheimer's disease, while the National Institutes of Health (NIH) subsumes dementia under the category of Serious Mental Illness. Data on the prevalence of Alzheimer's indicate increasing prevalence. Starting at age 65, the risk of developing the disease doubles every 5 years. By age 85 years and older, between 25% and 50% of people will exhibit signs of Alzheimer's disease. Up to 5.3 million Americans currently have Alzheimer's disease (Hebert, Scherr, Bienias, Bennett, & Evans, 2003). By 2050, the number is expected to more than double due to the aging of the population. Alzheimer's disease is the sixth leading cause of death in the United States and is the fifth leading cause among persons age 65 and older (Heron et al., 2009).

A recent meta-analysis (Prince et al., 2013) found global prevalence of dementia from all causes to be between 5% and 7% of adults age 60+. Two recent studies of dementia prevalence have shown some indication that prevalence may be declining. In one (Matthews et al., 2013), prevalence surveys of adults age 65+ were conducted almost 2 decades apart (1989 and 2008). After controlling for differences in the patient populations, the researchers found that the 2008 cohort had significantly lower prevalence of dementia. The second study (Christensen et al., 2013) took a slightly different approach. Those researchers assessed two cohorts of patients. One cohort was born in 1905 and was assessed in 1998 at age 93. The second cohort was born 10 years later, in 1915, and was assessed in 2010 at age 95. The 1915 cohort was found to have significantly lower prevalence of dementia. Both research teams concluded that the likely explanation was improved primary prevention of causes such as stroke.

Neither of the research teams found changes in the prevalence of Alzheimer's specifically, and it should also be noted that one study was conducted in the United Kingdom and the other in Denmark, so it cannot necessarily be concluded that primary prevention efforts in the United States have been similarly successful.

A limited number of studies have examined the prevalence of dementia among racial and ethnic groups. Differences in sampling methods and definitions of dementia, as well as difficulties controlling for variables such as level of education and bias in assessment batteries, limit the generalizability of results. However, results from individual studies suggest that the incidence and prevalence of dementia varies across racial and ethnic groups (Manly & Mayeux, 2004).

The Aging, Demographics, and Memory Study (ADAMS) used a nationally representative Health and Retirement Survey to estimate the prevalence of Alzheimer's disease (AD) and other dementias in the United States. Results were analyzed to determine the overall prevalence of dementia, as well as the relationship between dementia and variables such as education, gender, race (African American or Caucasian), and Apolipoprotein E (APOE) genotype. Controlling for education, gender, and APOE genotype, researchers found that African Americans were at a greater risk for dementia than Caucasians, although this difference was not statistically significant (Plassman et al., 2007).

Signs and Symptoms

The symptoms of dementia can be different depending on the diagnosis and the stage of the disease. Although late-stage signs and symptoms may be similar across etiologies, characteristic early symptoms can vary considerably. For example, individuals with frontotemporal dementia and Huntington's disease experience behavior changes and depression; those with primary progressive aphasia experience gradual loss of language function but relatively well-preserved memory; and individuals with Binswanger's disease (a type of vascular dementia) experience stroke-related neurological symptoms, including dysarthria and dysphagia (Hegde, 2006). Cultural values, views of the aging process, and beliefs relative to cognitive decline may influence a family's decisions about therapeutic services and may at times inhibit or delay seeking help until symptoms are beyond early or mild stages (Hart, Gallagher-Thompson, Davies, DiMinno, & Lessin, 1996).

Signs and Symptoms

In general, individuals with dementia experience a gradual loss of memory and other cognitive functions. As the disease progresses, early symptoms intensify, eventually affecting the ability to communicate effectively and function independently. Examples of common signs and symptoms of dementia are listed below.

Attention

Common attention deficits include

Learning and Memory

Common learning and memory deficits include

Reasoning and Executive Functioning

Common reasoning and executive functioning deficits include

Perceptual Abilities

Common perceptual deficits include

Language

Common language deficits include

Social Cognition and Behavior

Common social cognition and behavior deficits include

Impact of Cognitive Changes

Communication

Cognition and language are intrinsically and reciprocally related in both development and function. An impairment of language may disrupt one or more cognitive processes (e.g., attention, perception, memory, and executive functioning) and, similarly, an impairment of one or more cognitive processes may disrupt language and affect the individual's ability to communicate effectively.

Individuals who forget what they have recently heard, seen, or thought may have difficulty following a conversation; they often lose track of the topic, miss the point, and/or repeat themselves. With more significant memory decline, individuals may become disoriented to time and place and have difficulty remembering recent events. Verbal output may be reduced and less substantive, and they may become less efficient in expressing information. Attention, executive functioning, and processing deficits can affect the ability to actively engage in conversation, keep track of topic changes, and process information accurately and in a timely manner.

Feeding And Swallowing

In addition to the effects of neuromuscular and/or motor planning deficits associated with some conditions, the cognitive decline associated with dementia can impact feeding and swallowing. Individuals with dementia may forget to eat meals, initiate eating less often, or take in less food and drink than they normally would during meals, due to distractions in the environment. Reduced intake may eventually compromise nutrition. In addition, individuals with dementia may not attend to food in the mouth or may not remember to chew and initiate a swallow, placing them at risk for choking and aspiration pneumonia (Bourgeois & Hickey, 2009).

Causes

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).

Roles and Responsibilities

Speech-language pathologists (SLPs) play a central role in the screening, assessment, diagnosis, and treatment of persons with dementia. The professional roles and activities in speech-language pathology include clinical/educational services (diagnosis, assessment, planning, and treatment), prevention and advocacy, and education, administration, and research. See ASHA's Scope of Practice in Speech-Language Pathology (ASHA, 2007).

Appropriate roles for SLPs include

As indicated in the Code of Ethics (ASHA, 2010), 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

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.

Evidence Highlight

  • Although the Mini-Mental Status Examination (MMSE) is the best studied instrument for screening cognitive impairment, evidence indicates that the MMSE has demonstrated poor sensitivity (Lischka, Mendelsohn, Overend, & Forbes, 2012) and only fair positive predictive value (U.S. Preventive Services Task Force [USPSTF], 2003).
  • Evidence from one systematic review indicates that the Addenbrooke's Cognitive Examination (ACE) "was found to be the best screening tool in terms of predictability, accuracy, and feasibility" (Lischka et al., 2012, p. 310).
  • Evidence from several systematic reviews and guidelines (Appels & Scherder, 2010; Mitchell & Malladi, 2010; Pinto & Peters, 2009; USPSTF, 2003) suggests that clinicians can use the following other assessments to screen for dementia: The Functional Activities Questionnaire (FAQ); The Neurobehavioral Cognitive Screening Examination (NCSE; for patients with mild Alzheimer's disease or vascular dementia); Montreal Cognitive Assessment (MoCA); DEMTECT; Memory Alteration Test; MINI-Cog; Saint Louis University Mental Status Examination; Eurotest; and The Clock Drawing Test (CDT) for moderate and severe dementia.

See the Screening Instruments section of the dementia evidence map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.

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 may result in

A comprehensive assessment is sensitive to cultural and linguistic diversity and addresses the components within the World Health Organization (WHO) International Classification of Functioning, Disability and Health (ICF) framework (see ASHA's Scope of Practice in Speech-Language Pathology, ASHA, 2007; WHO, 2001), including body structures/functions, activities/participation, and contextual factors. Assessment should occur in the language(s) used by the person with dementia.

Assessment can be static (i.e., using procedures designed to describe current levels of functioning within relevant domains) and/or dynamic (i.e., an ongoing process using hypothesis-testing procedures to identify potentially successful intervention and support procedures). When dementia is caused by a progressive disease, periodic reevaluation (e.g., yearly) and adjustment of care plans become essential to meet changing needs.

Assessment typically includes

Expert Opinion

See the Assessment: Cognitive Communication section of the dementia evidence map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.

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

An instrumental evaluation may be performed to determine safety and identify effective treatment techniques or strategies, if the patient is able to respond appropriately and tolerate the procedure. The instrumental evaluation may provide additional information about the oral and pharyngeal bolus transit, airway protection, the impact of bolus texture and size, and appropriate pacing (Easterling & Robbins, 2008).

Expert Opinion

  • During a swallowing assessment, clinicians should conduct a detailed case history (Taylor-Goh, 2005) and evaluate seating and positioning, chewing and swallowing, and use of utensils (Tilly & Reed, 2006); in addition to mood, behavior, and attitude; environment; medication; weight loss; suddenness of onset; and capacity for treatment (Taylor-Goh, 2005).
  • Clinicians working in assisted living and skilled nursing facilities should monitor residents with dementia and swallowing difficulties on an ongoing basis (Tilly & Reed, 2006).

See the Assessment Areas section of the dementia evidence map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.

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.

Evidence Highlight

Cognitive-Communication

  • Kansagara and Freeman (2010) evaluated the several brief cognitive tests for use with veterans with dementia and reported the following reliability and validity findings:
    • The Mini-Cog has been validated in a large sample of the general population (Sensitivity: 76%-99%; Specificity: 83%-93%).
    • The St. Louis University Mental Status (SLUMS) Exam has high sensitivity and specificity, but has not been widely studied.
    • The Short Test of Mental Status12 (STMS) was researched in a primary care setting (Sensitivity: 82%-98%; Specificity: 49%-66%).
    • The Blessed Orientation-Memory-Concentration13 (BOMC) was noted to misclassify some individuals when they were evaluated in a bi-racial population (Sensitivity: 69%-100%; Specificity: 38%-94%).
    • The Montreal Cognitive Assessment (MOCA) has been evaluated in a memory clinic and was found to have a relatively long administration time and low specificity (35%-50%).

Swallowing

  • Evidence indicates that the Clinical Swallow Evaluation (CSE) poorly estimated the risk of aspiration as compared to the Fiberoptic Endoscopic Evaluation of Swallowing (FEES) and Videofluoroscopic Swallow Study (VFSS) and that the FEES has similar or possibly better sensitivity for the detection of laryngeal penetration and tracheal aspiration as compared to the VFSS (Alagiakrishnan, Bhanj, & Kurian, 2012).
  • The CSE should not be used in isolation to rule out aspiration in patients with dementia, and individuals at higher risk for aspiration should have an evaluation by VFSS or FEES to determine the appropriate diet consistency (Alagiakrishnan et al., 2012).

Quality of Life

  • Evidence from one systematic review (Ettema, Dröes, de Lange, Mellenbergh, & Ribbe, 2005) indicates that the reliability is generally acceptable for the following dementia-specific quality-of-life instruments: Dementia Care Mapping (DCM), Alzheimer's Disease Related Quality of Life (ADRQL), Quality of Life for Dementia (QOL-D), Quality of Life in Alzheimer's disease (QOL-AD), Dementia Quality of Life Instrument (D-QOL), and The Cornell-Brown Scale for Quality of Life in Dementia.

See the Assessment Instruments section of the dementia evidence map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.

Assessment in Long-Term Care Facilities

Passage of the Omnibus Budget Reconciliation Act in 1987 mandated evaluation of the physical and psychological status of residents in long-term care facilities at the time of admission and periodically thereafter. The required evaluation, known as the Minimum Data Set (MDS), includes questions about the ability of residents to hear, comprehend, and produce language. Although the law does not require that judgments about hearing and communicative function be made by SLPs, the inclusion of these questions on the MDS helped establish a role for SLPs with long-term care residents.

Treatment

Treatment for the cognitive-communication deficits associated with dementia addresses the specific needs of the individual, taking into consideration the stage of the illness. Most common dementia-associated diseases are progressive in nature, and speech-language pathologists (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. Interventions that enhance activity and participation through modification of contextual factors may be warranted even if the prognosis for improved body structure/function is limited.

SLPs consider the individual's age, education, premorbid information, social history, present social context, cultural and linguistic background, and vocational status (current or premorbid) in formulating realistic and functional treatment goals within the bounds of the cognitive-communication disorder and with consideration for the progressive nature of the disease. Goals are often set based on the individual's current level of functioning, which can be determined using standardized functional rating scales.

Decisions about goals and treatment options are made in collaboration with clients, families/caregivers, and other health professionals. Clinicians can work directly with the individual who has dementia or indirectly through environment modifications, caregiver training, or the development of therapeutic routines and activities.

Treatment also involves providing information and guidance to the individual, family/caregiver(s), and other significant persons about the nature of the disorder and the course of treatment. Treatment occurs in the language(s) used by the person with dementia either by a bilingual SLP or with the use of trained interpreters, when necessary. See bilingual service delivery.

Demographic shifts and immigration patterns have led to increased diversity among the elderly population and their caregivers in the United States. Cultural influences and familial expectations regarding roles may impact long-term care decisions, who makes these decisions, and the value of treatment and intervention (Hinton, Fox, & Levkoff, 1999; Low et al., 2009; Parker, Young, & Rogers, 2010; Whitlatch & Feinburg, 2003; Williams & Harvey, 2013; Winslow & Flaskerud, 2009). See cultural competence.

Although SLPs are autonomous professionals, successful intervention with individuals with cognitive-communication disorders often requires the collaborative involvement of other professionals. SLPs work collaboratively with neuropsychologists and other professional colleagues (e.g., audiologists), families, employers, and others who provide support to individuals with cognitive-communication disorders. SLPs (working within their scope of practice and at their individual level of competence) are uniquely qualified to treat communication disorders associated with cognitive impairments.

Consistent with the World Health Organization (WHO) framework, intervention is designed to

Because of the progressive nature of most dementia-associated illnesses, clinicians must determine whether individuals with dementia have the potential to benefit from cognitive-communication interventions. Positive prognostic factors are identified that demonstrate the feasibility of the proposed intervention.

Depending on assessment results, intervention addresses

Caregivers and Communication Partners

Those who provide care to individuals with dementia, including both professionals and family members, are faced with a number of challenges that can ultimately affect their own health and wellbeing (Schulz & Beach, 1999; Shaw et al., 1997). The changes in communication functioning brought about by cognitive decline can significantly affect day-to-day communication, resulting in considerable frustration. Research focused on individuals with AD suggests that training caregivers about dementia and teaching them to use strategies to enhance communication effectiveness may contribute to increased caregiver understanding of communication breakdowns; more successful conversational exchanges; and improved quality of life for the individual with dementia (Zientz, Rackley, Chapman, Hopper, & Mahendra, 2007).

Evidence Highlight

  • Evidence indicates that communication skills training with caregivers and health professionals may improve the quality of life and well-being of people with dementia in nursing home and home-care settings. More specifically, training improved positive behavior and satisfying interactions (Eggenberger, Heimerl, & Bennett, 2013).

Expert Opinion

  • Clinicians should focus on caregiver education and counseling to establish communication expectations and strategies (Taylor-Goh, 2005).

See the Service Delivery: Provider 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.

Evidence Highlights

  • Evidence indicates that compensatory techniques may be less effective than restorative strategies for improving cognition and functional abilities in individuals with Alzheimer's disease (Sitzer, Twamley, & Jeste, 2006).

There is mixed evidence regarding the use of cognitive-focused interventions with individuals with dementia:

  • Evidence from several reviews indicates that cognition-focused interventions have demonstrated effects on trained cognitive skills (Kurz, Leucht, & Lautenschlager, 2011; Sitzer et al., 2006), functional abilities (Sitzer et al., 2006), and performance-based activities of daily living (Sitzer et al., 2006) and that outcomes may be maintained for an average of 4.5 months ( Sitzer et al., 2006).
  • Evidence from another review indicates that specific cognitive intervention strategies may be beneficial for individuals with mild to moderate dementia in terms of learning facts and procedures; however, generalization and long-term maintenance may be limited, and improvement in overall cognitive functioning generally should not be expected (Hopper et al., 2013).
  • Finally, Bahar-Fuchs, Clare, and Woods (2013) concluded that there was insufficient evidence to support the efficacy of cognitive training for individuals with mild to moderate Alzheimer's disease and vascular dementia; however, noted that some gains in treatment may not be adequately captured by available standardized outcome measures.  The authors also suggested that there may be preliminary support for the use of contextualized individual cognitive rehabilitation for improving self-rated competence and satisfaction with activities of daily living.

See the Compensatory Treatments and Restorative Treatments  General Findings sections of the dementia evidence map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.

Assistive Technology (including hearing assistive technology)

Assistive technology (AT) is a generic term that includes assistive, adaptive, and rehabilitative devices and services for individuals with disabilities. An assistive technology device is any item, piece of equipment, or system—whether commercial, modified, or customized—that is used to increase, maintain, or improve the functional capabilities of a person with disabilities. Hearing Assistive Technology Systems (HATS) are available for individuals who currently use hearing technology, such as hearing aids and cochlear implants. HATS are also available for those with hearing loss that is untreated. Personal amplifiers and FM systems and other technology can enhance face-to-face communication. There are several commercially available and emerging assistive technologies that, with further interdisciplinary research and modifications, may have potential applications to dementia care (Bharucha et al., 2009).

Evidence Highlight

  • Evidence indicates that technology-based interventions (e.g., in-home technology support systems, computer-based programs, electronic memory aids, video monitoring and conferencing) offer future promise to increase safety in the home and reduce caregiver burden and total care costs for individuals with early-stage Alzheimer's disease (Buettner, Yu, & Burgener, 2010).

Expert Opinion

  • External assistive technology, such as a portable voice organizer or mobile phone, can be considered effective for adults with severe memory impairment as a result of neurodegenerative diseases, such as Alzheimer's disease (Piras, Borella, Incoccia, & Carlesimo, 2011).

See the Compensatory Treatments: Assistive Technology section of the dementia evidence map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.

Cognitive Stimulation Therapy

Cognitive stimulation therapy (CST) focuses on actively stimulating and engaging individuals with dementia by using theme-based activities in an optimal learning environment (typically, in a small-group setting).

Evidence Highlight

  • Evidence indicates that cognitive stimulation improves (Aguirre, Woods, Spector, & Orrell, 2013; Woods, Aguirre, Spector, & Orrell, 2012) or maintains (Yuill & Hollis, 2011) cognitive function in individuals with dementia.
  • Evidence is mixed regarding the potential benefit of cognitive stimulation on outcomes of quality of life and well-being. One systematic review indicated that cognitive stimulation improves self-reported quality of life and well-being (Aguirre et al., 2013); one indicated that findings were "promising" for these outcomes ( Woods et al., 2012, p. 2); and one systematic review suggested that there was insufficient evidence to conclude that group or individual cognitive stimulation therapy improves self-rated quality of life for individuals with dementia (Cooper et al., 2012).

See the Treatment: Cognitive Stimulation section of the dementia evidence map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.

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).

External Memory Aids

External memory aids are aimed at helping individuals with memory problems in their day-to-day activities. They include electronic and non-electronic devices, as well as environmental adjustments. Examples include personal digital assistants (PDAs), message boards, clocks, and pictures.

Evidence Highlights

  • Evidence indicates that verbal instruction provided by way of an electronic memory aid may improve learning outcomes associated with activities of daily living for individuals with mild to moderate dementia (Hopper et al., 2013).
  • Additionally, evidence indicates that a combination of memory aids and caregiver training may improve verbal communication between individuals with Alzheimer's disease and their caregivers (Egan, Bérubé, Racine, Leonard, & Rochon, 2010).

Expert Opinion

  • Clinicians should consider using clocks, calendars, family pictures, and other orienting stimuli to reduce cognitive decline in individuals with dementia (Maslow, Selstad, & Denman, 2002).

See the Treatments: Memory Training Programs of the dementia evidence map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.

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.

Evidence Highlights

  • There is mixed evidence regarding the use of memory re-training programs. Evidence from one guideline (Piras et al., 2011) indicates that, overall, memory re-training programs are not effective for patients with severe or mild memory impairments secondary to vascular or Alzheimer's dementia; however, the guideline does recommend the errorless learning approach as a domain-specific learning strategy. A systematic review conducted by Hopper et al. (2013) similarly concluded that all participants with dementia learned facts and procedures using errorless learning; however, "learning under [errorless learning] conditions was not always superior to learning under errorful/trial-and-error conditions" (p. 141). Findings from the Hopper et al. review also indicate that spaced retrieval was associated with improved recall of facts and performance of tasks by individuals with varying levels of dementia severity.

Expert Opinion

  • Expert opinion regarding memory training programs is also mixed. The Italian Association of Psychogeriatrics (Caltagirone et al., 2005) suggests that, although some patients may derive benefit, "generally, there is only limited evidence that memory training, not associated with other techniques that involve cognitive and functional training, is effective for improving cognitive function in AD patients" (p. 11). Maslow et al. (2002) recommend that, to reduce cognitive decline, memory training should be considered only in the early stages of dementia.

See the Treatments: Memory Training section of the dementia evidence map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.

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.

Reality Orientation (RO)

Reality Orientation (RO) is a technique to reduce confusion and improve quality of life for individuals with dementia by providing orienting information (e.g., time, place, or person) to reinforce understanding and awareness of the environment. Information is repeated at regular intervals throughout the day.

Evidence Highlight

  • Evidence has shown reality orientation to be effective in improving cognitive ability, as measured by the Mini-Mental State Examination, and that these improvements were generally maintained at follow-up (Bates, Boote, & Beverley, 2004).

Expert Opinion

  • There are mixed opinions regarding the use of reality orientation therapy. The Work Group on Alzheimer's Disease and Other Dementias (Rabins et al., 2007) concluded that cognition-oriented treatments, including reality orientation, "are unlikely to have a persistent benefit and have been associated with frustration in some patients" (p. 12). The Italian Association of Psychogeriatrics ( Caltagirone et al., 2005) suggests that reality orientation should be considered in all patients as a practice standard.

See the Treatments: Reality Orientation section of the dementia evidence map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.

Reminiscence Therapy (RT)

Reminiscence Therapy (RT) is an intervention approach that uses the life history and experience of an individual to improve his or her sense of well-being. RT programs typically involve the discussion of past activities, events, and experiences—using tangible prompts, such as photographs, familiar items, and music from the past. The customized nature and individual focus of reminiscence therapy make it an intervention particularly well suited for individuals from diverse backgrounds (Harris, 1997).

Evidence Highlight

  • Evidence indicates that individual reminiscence therapy-specifically including the components of (a) a life review process, (b) specific memory triggers, and (c) the production of a life story book-has been associated with psychosocial benefits for individuals with dementia. Evidence does not support a more general form of individual reminiscence therapy (Subramaniam & Woods, 2012).

See the Treatments: Reminescence Therapy of the dementia evidence map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.

Simulated Presence Therapy (SimPres)

Simulated presence therapy (SIMPRES) is an emotion-oriented approach aimed at reducing levels of anxiety and challenging behaviors by playing audio recordings of the voices of close relatives of the individual. SIMPRES has been used to improve well-being (e.g., decrease agitation and withdrawal behaviors) in individuals with Alzheimer's disease who have adequate hearing and have retained communication skills (Bayles et al., 2006).

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.

Expert Opinion

  • The Italian Association of Psychogeriatrics (Caltagirone et al., 2005) suggests as a practice option that validation therapy be used for research purposes only.

See the Treatments: Validation Therapy section of the dementia evidence map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.

Feeding and Swallowing Treatment

Individuals progressing through different stages of dementia may demonstrate difficulty feeding and swallowing. For example, individuals with moderately severe cognitive decline often demonstrate difficulty using a knife; individuals with severe cognitive decline may demonstrate difficulties discriminating between utensils; and individuals with very severe cognitive decline may be easily overwhelmed and require cues to locate food on the plate and to swallow (Voyzey, 2010). Swallowing function may also be affected by reduced muscle strength and coordination. Once appropriate feeding and swallowing strategies, postures, and consistencies have been identified, the clinician can train caregivers to provide feeding support and cuing as appropriate.

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.

Expert Opinion

  • The Alzheimer's Association (Tilly & Reed, 2007) suggests that dysphagia can be managed through the use of hands-on assistance with eating, modifying food texture, or increasing the thickness of foods. Dietary restrictions may need to be modified if individuals are not eating enough to maintain their weight.

See the Treatment: Swallowing section of the dementia evidence map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.

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.

Evidence Highlight

See the Treatment: Postural Changes section of the dementia evidence map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.

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.

Evidence Highlight

Expert Opinion

  • The European Society for Clinical Nutrition and Metabolism (ESPEN) guidelines (Volkert et al., 2006) suggest that oral nutritional supplements, and occasionally also tube feeding, should be considered to ensure appropriate nutrition for individuals with early and moderate dementia.
  • Several guidelines indicate that tube feeding is not recommended for individuals with terminal (Volkert et al., 2006) or severe (NICE, 2006) dementia. NICE (2006) also stresses that ethical and legal principles must be applied when making decisions about withholding nutritional support.
  • The NICE (2006) guidelines recommend that individuals with dementia eat and drink by mouth as long as possible and that tube feeding or other forms of nutritional support be considered if the dysphagia is thought to be a transient condition.
  • The Italian Association of Psychogeriatrics (Caltagirone et al., 2005) indicates that percutaneous endoscopic gastrostomy (PEG) should be considered only for patients who are likely to benefit from its use-for example, individuals at risk for, or in initial stages of, a reversible malnutrition.

See the Treatment: Tube Feeding section of the dementia evidence map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.

Treatment For Hearing Loss

The presence of dementia should not preclude fitting with a hearing aid; however, ongoing support may be necessary to ensure compliance with hearing aid use (Lewsen & Cashman, 1997). Although there is no current evidence that hearing aids can improve cognition in persons with dementia, problem behaviors (e.g., repeating questions, negative statements, forgetting, restlessness, pacing, "hearing things") can be improved with the use of amplification (Palmer, Adams, Bourgeouis, Durrant, & Rossi, 1999). In addition, elderly patients fitted with hearing aids during the early stages of hearing loss may retain cognitive function better than those who postpone fitting of hearing aids (Obuchi, Harashima, & Shiroma, 2011).

Given the relationship between hearing loss and dementia and the co-occurrence of hearing loss and dementia in aging adults, audiologists play a significant role in the treatment of these individuals. In addition to assessing the need for HATS, hearing aids, and cochlear implants, audiologists educate family members and caregivers on strategies to improve communication at home (e.g., improving listening environments) and provide ongoing counseling and support in the use of technology.

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.).

Expert Opinion

  • The Alzheimer's Association (Tilly & Reed, 2006) indicates that, for individuals nearing the end of life, artificial nutrition and hydration may be withheld in accordance with the patient's or family's wishes. These individuals require good oral care, and their mouths should be kept moistened.

See the Treatment: Swallowing section of the dementia evidence map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.

Service Delivery

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

See the Service Delivery section of the dementia evidence map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.

Evidence Highlight

  • Greater effects have been observed for studies using individual cognitive treatment modalities over studies using group modalities (Sitzer et al., 2006).

See the Service Delivery: Format section of the dementia evidence map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.

Resources

ASHA Resources

Ardila, A., & Ramos, E. (2010). Bilingualism and aging. Perspectives on Communication Disorders and Sciences in Culturally and Linguistically Diverse Populations, 17(3), 74-81. doi:10.1044/cds17.3.74.

Common Classifications of Dementia

Consumer Information:  Dementia

Cultural Competence Practice Portal Page

End of Life Resources and References

Patient Education Materials: Audiology Information Series

Riquelme, L. F. (2004, April 13). Cultural competence in dysphagia. The ASHA Leader.

SIG 2's Perspectives on Neurophysiology and Neurogenic Speech and Language Disorder

SIG 13's Perspectives on Swallowing and Swallowing Disorders (Dysphagia)

SIG 15's Perspectives on Gerontology

Organizations and Related Content

Alzheimer's Association New York City Chapter: Communicating

Alzheimer's Association

 Alzheimer's Foundation of America

American Federal for Aging Research (AFAR)

Dementia Research Center

Dementia.com

Gerontological Society of America

Harris Communications: Assistive Products for Deaf and Hard of Hearing

HITEC: Assistive Products for Deaf and Hard of Hearing

Medline Plus: Dementia

National Institute of Neurological Disorders and Stroke

National Institute on Aging:  Alzheimer's Disease Education and Referral Center

Remember me? A guide to Alzheimer's disease and hearing loss

Weitbrecht Communications: Solutions for people with hearing loss

References

Aguirre, E., Woods, R. T., Spector, A., & Orrell, M. (2013). Cognitive stimulation for dementia: A systematic review of the evidence of effectiveness from randomized controlled trials. Ageing Research Reviews, 12, 253-262. doi:10.1016/j.arr.2012.07.001.

Alagiakrishnan, K., Bhanji, R. A., & Kurian, M. (2012). Evaluation and management of oropharyngeal dysphagia in different types of dementia: A systematic review. Archives of Gerontology and Geriatrics, 56, 1-9. doi:10.1016/j.archger.2012.04.011.

Albert, M. S., DeKosky, S. T., Dickson, D., Dubois, B., Feldman, H., Fox, N. C., … Phelps, C. H. (2011). The diagnosis of mild cognitive impairment due to Alzheimer's disease: Recommendations from the National Institute on Aging-Alzheimer's Association workgroups on diagnostic guidelines for Alzheimer's disease. Alzheimer's & Dementia, 7(3), 270-279.

Amieva, H., Jacqmin-Gadda, H., Orgogozo, J. M., Le Carret, N., Helmer, C., Letenneur, L., ... Dartigues, J. F. (2005). The 9 year cognitive decline before dementia of the Alzheimer type: A prospective population-based study. Brain, 128(5), 1093-1101.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). Washington, DC: Author.

American Speech-Language-Hearing Association. (2007). Scope of practice in speech-language pathology [Scope of practice]. Available from www.asha.org/policy.

American Speech-Language-Hearing Association. (2010). Code of ethics [Ethics]. Available from www.asha.org/policy.

American Speech-Language-Hearing Association. (n.d.). End-of-life issues in speech-language pathology. Retrieved from www.asha.org/slp/clinical/endoflife/.

Appels, B. A., & Scherder, E. (2010). The diagnostic accuracy of dementia-screening instruments with an administration time of 10 to 45 minutes for use in secondary care: A systematic review. American Journal of Alzheimer's Disease & Other Dementias, 25, 301-316.

Bahar-Fuchs, A., Clare., L., & Woods (2013). Cognitive Training and Cognitive Rehabilitation for Mild to Moderate Alzheimer's Disease and Vascular Dementia. Cochrane Database of Systematic Reviews (6), CD003260.

Bates, J., Boote, J., & Beverley, C. (2004). Psychosocial interventions for people with a milder dementing illness: A systematic review. Journal of Advanced Nursing, 45, 644-658.

Bayles, K. A., Kim, E., Chapman, S. B., Zientz, J., Rackley, A., Mahendra, N., ... Cleary, S. J. (2006). Evidence-based practice recommendations for working with individuals with dementia: Simulated presence therapy. Journal of Medical Speech Language Pathology, 14(3), xiii.

Bayles, K. A., & Tomoeda, C. K. (1993). Arizona Battery for Communication Disorders of Dementia. Austin, TX: PRO-ED.

Bayles, K. A., & Tomoeda, C. K. (2007). Cognitive-communication disorders of dementia. San Diego, CA: Plural.

Bennett, D. A., Schneider, J. A., Arvanitakis, Z., Kelly, J. F., Aggarwal, N. T., Shah, R. C., & Wilson, R. S. (2006). Neuropathology of older persons without cognitive impairment from two community-based studies. Neurology, 66(12), 1837-1844.

Bharucha, A. J., Anand, V., Forlizzi, J., Dew, M. A., Reynolds, C. F., III, Stevens, S., & Wactlar, H. (2009). Intelligent assistive technology applications to dementia care: Current capabilities, limitations, and future challenges. The American Journal of Geriatric Psychiatry, 17(2), 88-104.

Bialystok, E., Craik, F., & Freedman, M. (2007). Bilingualism as a protection against the onset of symptoms of dementia. Neuropsychologia, 45(2), 459--464.

Bourgeois, M. S., & Hickey, E. M. (2009). Dementia: From diagnosis to management-a functional approach. New York, NY: Psychological Press.

Buettner, L. L., Yu, F., & Burgener, S. C. (2010). Evidence supporting technology-based interventions for people with early-stage Alzheimer's disease. Journal of Gerontological Nursing, 36(10), 15-19.

Burkhalter, C. L., Allen, R. S., Skaar, D. C., Crittenden, J., & Burgio, L. D. (2009). Examining the effectiveness of traditional audiological assessments for nursing home residents with dementia-related behaviors. Journal of the American Academy of Audiology, 20, 529-538.

Brush, J., Sanford, J., Fleder, H., Bruce, C., & Calkins, M. (2011). Evaluating and modifying the communication environment for people with dementia. Perspectives on Gerontology, 16(2), 32-40.

Caltagirone, C., Bianchetti, A., Di Luca, M., Mecocci, P., Padovani, A., Pirfo, E., … Musicco, M. (2005). Guidelines for the treatment of Alzheimer's disease from the Italian Association of Psychogeriatrics. Drugs & Aging, 22, 1-26.

Christensen, K., Thinggaard, M., Oksuzyan, A., Steenstrup, T., Andersen-Ranberg, K., Jeune, B., … Vaupel, J. (2013). Physical and cognitive functioning of people older than 90 years: A comparison of two Danish cohorts born 10 years apart. The Lancet. Advanced online publication. doi:10.1016/S0140-6736(13)60777-1.

Cooper, C., Mukadam, N., Katona, C., Lyketsos, C. G., Ames, D., Rabins, P., … Livingston, G. (2012). Systematic review of the effectiveness of non-pharmacological interventions to improve quality of life of people with dementia. International Psychogeriatrics, 24, 856-870. doi:10.1017/S1041610211002614.

Craik, F., Bialystok, E., & Freedman, M. (2010). Delaying the onset of Alzheimer disease. Bilingualism as a form of cognitive reserve. Neurology, 75, 1726-1729.

Easterling ,C. S., & Robbins, E. (2008). Dementia and dysphagia. Geriatric Nursing, 29(4), 275-285. doi:10.1016/j.gerinurse.2007.10.015.

Egan, M., Bérubé, D., Racine, G., Leonard, C., & Rochon, E. (2010). Methods to enhance verbal communication between individuals with Alzheimer's disease and their formal and informal caregivers: A systematic review. International Journal of Alzheimer's Disease. doi:10.4061/2010/906818.

Eggenberger, E., Heimerl, K., & Bennett, M.I. (2013). Communication skills training in dementia care: A systematic review of effectiveness, training content, and didactic methods in different care settings. International Psychogeriatrics, 25, 345-358. doi:10.1017/S1041610212001664.

Ettema, T. P., Dröes, R., de Lange, J., Mellenbergh, G. J., & Ribbe, M. W. (2005). A review of quality of life instruments used in dementia. Quality of Life Research, 14, 675-686.

Fadil, H., Borazanci, A., Ait Ben Haddou, E., Yahyaoui, M., Korniychuk, E., Jaffe, S. L., & Minagar, A. (2009). Early onset dementia. International Review of Neurobiology, 84, 245-262.

Feil, N. (1982). Validation: The Feil method. How to help the disorientated old-old. Cleveland, OH: Feil Productions.

Friedland, D., & Miller, N. (1999). Language mixing in bilingual speakers with Alzheimer's dementia: A conversation analysis approach. Aphasiology, 13, 427-444.

Gallacher, J., Ilubaera, V., Ben-Shlomo, Y., Bayer, A., Fish, M., Babisch, W., & Elwood, P. (2012). Auditory threshold, phonologic demand, and incident dementia. Neurology, 79(15), 1583-1590.

Hanson, L. C., Ersek, M., Gilliam, R., & Carey, T. S. (2011). Oral feeding options for people with dementia: A systematic review. The American Geriatrics Society, 59, 463-472. doi:10.1111/j.1532-5415.2011.03320.x.

Harris, J. L. (1997). Reminiscence: A culturally and developmentally appropriate language intervention for older adults. American Journal of Speech-Language Pathology, 6(3), 19-26.

Hart, V. R., Gallagher-Thompson, D., Davies, H. D., DiMinno, M., & Lessin, P. J. (1996). Strategies for increasing participation of ethnic minorities in Alzheimer's disease diagnostic centers: A multifaceted approach in California. Gerontologist, 36, 259-262.

Hegde, M. N. (2006). A coursebook on aphasia and other neurogenic language disorders (3rd ed.). Clifton Park, NY: Delmar.

Hebert, L. E., Scherr, P. A., Bienias, J. L., Bennett, D. A., & Evans, D. A. (2003). Alzheimer disease in the US population: Prevalence estimates using the 2000 census. Archives of Neurology, 60(8), 1119-1122.

Heron, M. P., Hoyert, D. L., Murphy, S. L., Xu, J. Q., Kochanek, K. D., & Tejada-Vera, B. (2009). Deaths: Final data for 2006.National Vital Statistics Reports, 57(14). Hyattsville, MD: U.S. Department of Health and Human Services. National Center for Health Statistics.

Hinton, W. L., Fox, K., & Levkoff, S. (1999). Introduction: Exploring the relationship among aging, ethnicity, and family dementia caregiving. Culture, Medicine and Psychiatry, 23, 403-413.

Hopper, T., Bourgeois, M., Pimentel, J., Qualls, C. D., Hickey, E., Frymark, T., & Schooling, T. (2013). An evidence-based systematic review on cognitive interventions for individuals with dementia. American Journal of Speech-Language Pathology, 22, 126-145. doi:10.1044/1058-0360(2012/11-0137).

Horner, J, Alberts, M. J., Dawson, D. V., & Cook, G. M. (1994). Swallowing in Alzheimer's disease. Alzheimer's Disease and Associated Disorders, 8(3), 177-189.

Jefferies, K., & Agrawal, N. (2009). Early-onset dementia. Advances in Psychiatric Treatment, 15(5), 380-388.

Johnson, A. F., & Jacobson, B. H. (2007). Medical speech-language pathology: A practitioner ́s guide-Second Edition. New York, NY: Thieme.

Joint Commission on Accreditation of Healthcare Organizations. (2004). Comprehensive accreditation manual for hospitals: The official handbook . Oakbrook Terrace, IL: Author.

Kansagara, D., & Freeman, M. (2010). A systematic evidence review of the signs and symptoms of dementia and brief cognitive tests available in Veterans Affairs (VA-ESP Project #05-225). Retrieved from www.hsrd.research.va.gov/publications/esp/dementia.pdf.

Kean, J., & Locke, D. E. (2008). Neuropsychological consequences of cancer and cancer treatment. Perspectives on Neurophysiology and Neurogenic Speech and Language Disorders, 18(4), 144-151.

Key-DeLyria, S. (2013). What are the methods for diagnosing MCI? Neurophysiology and Neurogenic Speech and Language Disorders, 23, 14-22.

Kurz, A. F., Leucht, S., & Lautenschlager, N. T. (2011). The clinical significance of cognition-focused interventions for cognitively impaired older adults: A systematic review of randomized controlled trials. International Psychogeriatrics, 23, 1364-1375. doi:10.1017/S1041610211001001.

Landes, T. L. (1999). Ethical issues involved in patients' rights to refuse artificially administered nutrition and hydration and implications for the speech-language pathologist. American Journal of Speech-Language Pathology, 8, 109-117.

Lewsen, B. J., & Cashman, M. (1997). Hearing aids and assistive listening devices in long-term care. Canadian Journal of Speech-Language Pathology and Audiology, 21(3), 149-152.

Lin, F. R., Metter, E. J., O'Brien, R. J., Resnick, S. M., Zondermand, A. B., & Ferrucci, L. (2011). Hearing loss and incident dementia. Archives of Neurology, 68(2), 214-220.

Lischka, A. R., Mendelsohn, M., Overend, T., & Forbes, D. (2012). A systematic review of screening tools for predicting the development of dementia. Canadian Journal on Aging, 31, 295-311. doi:10.1017/S0714980812000220.

Lovestone, S. (1999). Early diagnosis and the clinical genetics of Alzheimer's disease. Journal of Neurology, 246(2), 69-72.

Low, L. F., Draper, B., Cheng, A., Cruysmans, B., Hayward-Wright, N., Jeon, Y. H., … Brodaty, H. (2009). Future research on dementia relating to culturally and linguistically diverse communities. Australasian Journal on Ageing, 28(3), 144-148.

Mahendra, N., & Hopper, T. (2013). Dementia and related cognitive disorders. In I. Papathanasiou, P. Coppens, & C. Potagas (Eds.), Aphasia and related neurogenic communication disorders (pp. 397-430). Burlington, MA: Jones & Bartlett Learning, LLC.

Manly, J. J., & Mayeux, R. (2004). Ethnic differences in dementia and Alzheimer's disease. In N.B. Anderson, R. A. Bulatao, & B. Cohen (Eds.), Critical perspectives on racial and ethnic differences in health in late life. Washington, DC: National Academies Press.

Matthews, F., Arthur, A., Barnes, L., Bond, J., Jagger, C., Robinson, L., & Brayne, C. (2013). A two-decade comparison of prevalence of dementia in individuals aged 65 years and older from three geographical areas of England: Results of the Cognitive Function and Ageing Study I and II. The Lancet. Advance online publication. Retrieved from doi.org/10.1016/S0140-6736(13)61570-6.

McMurtray, A., Clark, D. G., Christine, D., & Mendez, M. F. (2006). Early-onset dementia: Frequency and causes compared to late-onset dementia. Dementia and Geriatric Cognitive Disorders, 21(2), 59-64.

Mendez, M. F., Perryman, K. M., Pontón, M. O., & Cummings, J. L. (1999). Bilingualism and dementia. The Journal of Neuropsychiatry and Clinical Neurosciences, 11(3), 411-412.

Mitchell, A. J., & Malladi, S. (2010). Screening and case-finding tools for the detection of dementia. Part I: Evidence-based meta-analysis of multidomain tests. American Journal of Geriatric Psychiatry, 18, 759-782.

Montessori, M. (2008). The Montessori method. Radford, VA: Wilder Publications, LLC.

National Institute for Health and Clinical Excellence (NICE). (2006). Dementia: The NICE-SCIE guideline on supporting people with dementia and their careers in health and social care. London, UK: NICE.

National Institute on Deafness and Other Communication Disorders (NIDCD). (2010). Quick statistics. Retrieved from www.nidcd.nih.gov/health/statistics/Pages/quick.aspx.

National Institute of Neurological Disorders and Stroke (NINDS). (2013). Retrieved from www.ninds.nih.gov/index.htm.

Obuchi, C., Harashima, T., & Shiroma, M. (2011). Age-related changes in auditory and cognitive abilities in elderly persons with hearing aids fitted and the initial stages of hearing loss. Audiology Research, 1(e1), 40­41.

Omnibus Budget Reconciliation Act, Pub. L. N. 100-203 § 483.15 Stat. 161-163.

Palmer, C. V., Adams, S. W., Bourgeouis, M., Durrant, J., & Rossie, M. (1999). Reduction in caregiver-identified problem behaviors in patients with Alzheimer disease post hearing aid fitting. Journal of Speech, Language, and Hearing Research, 42, 312-328.

Parker, J., Young, A., & Rogers, K. (2010). My Mum's story: A deaf daughter discusses her Deaf mother's experience of dementia. Dementia, 9, 5-20.

Peelle, J. E., Troiani, V., Grossman, M., & Wingfield, A. (2011). Hearing loss in older adults affects neural systems supporting speech comprehension. The Journal of Neuroscience, 31(35), 12638-12643.

Pichora-Fuller, M. K., Dupuis, K., Reed, M., & Lemke, U. (2013). Helping older people with cognitive decline communicate: Hearing aids as part of a broader rehabilitation approach. Seminars in Hearing 34(4), 308-330.

Pinto, E. & Peters, E. (2009). Literature review of the Clock Drawing Test as a tool for cognitive screening. Dementia and Geriatric Cognitive Disorders, 27, 201-213. doi:10.1159/000203344.

Piras, F., Borella, E., Incoccia, C., & Carlesimo, G.A. (2011). Evidence-based practice recommendations for memory rehabilitation. European Journal of Physical and Rehabilitation Medicine, 47, 149-175.

Plassman, B. L., Langa, K. M., Fisher, G. G., Heeringa, S. G., Weir, D. R., Ofstedal, M. B., ... Wallace, R. B. (2007). Prevalence of dementia in the United States: The aging, demographics, and memory study. Neuroepidemiology, 29(1-2), 125-132.

Prince, M., Bryce, R., Albanese, E., Wimo, A., Ribeiro, W., & Ferri, C. P. (2013). The global prevalence of dementia: A systematic review and metaanalysis. Alzheimer's Dementia, 9(1), 63-75.

Qualls, C. (2005). Neurobiology of normal aging, mild cognitive impairment, and Alzheimer's disease: A tutorial. Gerontology,10, 2-7.

Rabin, A., Paré, N., Saykin, A. J., Brown, M. J., Wishart, H. A., Flashman, L. A., & Santulli, R. (2009). Differential memory test sensitivity for diagnosing amnestic mild cognitive impairment and predicting conversion to Alzheimer's disease. Neuropsychology, Development, and Cognition, Section B, Aging, Neuropsychology and Cognition, 16 (3), 357-376.

Rabins, P. V., Blacker, D., Rovner, B. W., Rummans, T., Schneider, L. S., Tariot, P. N., & Blass, D. M. (2007). American Psychiatric Association practice guideline for the treatment of patients with Alzheimer's disease and other dementias (2nd ed.). American Journal of Psychiatry, 164, 5-56.

Satz, P. (1993). Brain reserve capacity on symptom onset after brain injury: A formulation and review of evidence for threshold theory. Neuropsychology, 7(3), 273-295.

Sampson, E. L., Candy, B., & Jones, L. (2009). Enteral tube feeding for older people with advanced dementia. Cochrane Database of Systematic Reviews, Issue 2 (Article No. CD007209). doi:10.1002/14651858.CD007209.pub2.

Schulz, R., & Beach, S. R. (1999). Caregiving as a risk factor for mortality. The Journal of the American Medical Association, 282(23), 2215-2219.

Shaw, W. S., Patterson, T. L., Semple, S. J., Ho, S., Irwin, M. R., Hauger, R. L., & Grant, I. (1997). Longitudinal analysis of multiple indicators of health decline among spousal caregivers. Annals of Behavioral Medicine, 19(2), 101-109.

Sitzer, D. I., Twamley, E. W., & Jeste, D. V. (2006). Cognitive training in Alzheimer's disease: A meta-analysis of the literature. Acta Psychiatrica Scandinavica, 114, 75-90. doi:10.1111/j.1600-0447.2006.00789.x.

Stern, Y. (2002). What is cognitive reserve? Theory and research application of the reserve concept. Journal of the International Neuropsychological Society, 8(3), 448-460.

Stern, Y. (2003). The concept of cognitive reserve: A catalyst for research. Journal of Clinical and Experimental Neuropsychology, 25, 589-593.

Stern, Y. (2009). Cognitive reserve. Neuropsychologia, 47(10), 2015-2028.

Subramaniam, P., & Woods, B. (2012). The impact of individual reminiscence therapy for people with dementia: Systematic review. Expert Review of Neurotherapeutics, 12, 545-555. doi:10.1586/ERN.12.35.

Takayama, Y. (2010). A delayed recall battery as a sensitive screening for mild cognitive impairment: Follow-up study of memory clinic patients after 10 years. Journal of Medical and Dental Sciences, 57, 177-184.

Taylor-Goh, S. (2005). 5.10 Disorders of mental health and dementia. In Royal College of Speech & Language Therapists (RCSLT) Clinical Guidelines (pp. 83-91). Bicester, UK: Speechmark Publishing.

Tilly, J., & Reed, P. (Eds.). (2006). Dementia care practice recommendations for assisted living residences and nursing homes: Phases 1 and 2. Retrieved from www.alz.org/national/documents/brochure_dcprphases1n2.pdf.

Tilly, J., & Reed, P. (Eds.). (2007). Dementia care practice recommendations for assisted living residences and nursing homes: Phase 3 end-of-life care. Retrieved from www.alz.org/national/documents/brochure_dcprphase3.pdf.

U.S. Preventive Services Task Force (USPSTF). (2003). Screening for dementia (AHRQ Publication No. 03-520A). Retrieved from www.uspreventiveservicestaskforce.org/3rduspstf/dementia/dementrr.pdf.

Volkert, D., Berner, Y. N., Berry, E., Cederholdm, T., Coti Bertrand, P., Milne, A., … Lochs, H. (2006). ESPEN guidelines on enteral nutrition: Geriatrics. Clinical Nutrition, 25, 330-360. doi:10.1016/j.clnu.2006.01.012.

Voyzey, G. A. (2010). Feeding and swallowing strategies for the individual with dementia. Perspectives on Gerontology, 15(2), 48-53. doi:10.1044/gero15.2.48.

Wechsler, D. (1999). Wechsler Memory Scale-Third Edition. San Antonio, TX: Harcourt Assessment.

Williams, S. W., & Harvey, I. S. (2013). Culture, race, and SES: Application to end of life decision making for African American caregivers. Perspectives on Gerontology, 18(2), 69-76.

Whitlatch, C., & Feinberg,L. (2003). Planning for the future together in culturally diverse families: Making everyday care decisions. Alzheimer's Care Quarterly, 4(1), 50-61.

Winslow, B., & Flaskerud, J. (2009). Deciding to place a relative in long-term care: "We don't really do that." Issues in Mental Health Nursing, 30, 197-198.

Woods, B., Aguirre, E., Spector, A. E., & Orrell, M. (2012). Cognitive stimulation to improve functioning in people with dementia. Cochrane Database of Systematic Reviews, Issue 2 (Article No. CD005562). doi:0.1002/14651858.CD005562.pub2.

World Health Organization. (2001). International Classification of Functioning, Disability and Health. Geneva, Switzerland: Author.

Yuill, N., & Hollis, V. (2011). A systematic review of cognitive stimulation therapy for older adults with mild to moderate dementia: An occupational therapy perspective. Occupational Therapy International, 18, 163-186. doi:10.1002/oti.315.

Zientz, J., Rackley, A., Chapman, S. B., Hopper, T., & Mahendra, N. K. E. (2007). Evidence-based practice recommendations for dementia: Educating caregivers about Alzheimer's disease and training communication strategies. Journal of Medical Speech-Language Pathology, 15(1), 53-64.