Individuals with dementia are often on the caseloads of speech-language pathologists working in all sectors of health care, from acute to long-term care settings. Discussions about how best to serve this ever-growing group continue to focus on issues of assessment, treatment planning, and outcome measurement.

At the ASHA Health Care 2005 conference, Michelle Bourgeois, Rosemary Lubinski, and I shared information, perspectives, and research evidence to guide clinicians in their work with individuals who have dementia. What follows is a brief synopsis of some of the information covered, including the organizing framework of the ICF model, principles of comprehensive assessment, goal selection, management strategies, and outcome measurement.

The ICF model

The International Classification of Functioning, Disability, and Health (ICF) published by the World Health Organization (WHO; 2001), facilitates a holistic view of clients' functioning and provides a context for assessment and treatment. The recent revision of the ICF in 2001 and subsequent inclusion of contextual factors (environmental and personal) and their interaction with functioning, disability, and health is noteworthy as it pertains to irreversible dementing diseases. Rather than focusing on disease states and their devastating effect on cognitive function, clinicians can focus on other aspects of functioning that may be more amenable to behavioral intervention.

Assessment

Clinicians must screen basic sensory and cognitive functions and conduct a thorough assessment of cognitive-communication abilities of individuals with dementia. Several standardized measures exist and are available in published format.

To evaluate the impact of cognitive-communication impairments on the overall functioning of individuals with dementia, clinicians should also perform a systematic observation of individuals with dementia in their environments and conduct a careful interview of caregivers and other frequent communication partners. Barriers and facilitators of function, such as physical, social, and attitudinal environmental factors (WHO, 2001) should be documented. At this stage clinicians may also want to use dynamic assessment procedures to determine the client's potential to learn (e.g., how the client responds to cues, what types of errors are made during tasks).

A comprehensive evaluation, therefore, includes many components in addition to standardized testing. By using multiple measures aimed at different levels of the ICF model, clinicians will have a wealth of information to guide them in selecting appropriate goals and management strategies.

Management strategies

Increasing reliance on more intact cognitive abilities to compensate for deficient ones is a core principle of dementia management programs (Bayles & Tomoeda, 1997). In addition, other strengths (e.g., ability to engage in social activities, strong family support, nurturing environment) should also be exploited when selecting treatment goals.

As in any communication disorder, goals designed for individuals with dementia should be reasonable and necessary. Appropriate goals should involve modification of discrete behaviors (of caregivers and clients) that have an impact on the individual's ability to communicate and participate in desired activities. For example, SLPs may teach caregivers positive communication strategies that help to decrease aberrant (e.g., disruptive vocalizations) or increase desirable (e.g., conversational initiations) communication by the person with dementia.

Clinicians may also work directly with clients to help them improve specific communication skills such as saying a caregiver's name, making choices during activities of daily living, or improving the ability to read signs for way-finding (Bayles & Tomoeda, 1997).

Several treatment techniques are available to help individuals with dementia achieve optimal cognitive-communication function. Some of the evidence-based techniques discussed were as follows:

Validation therapy

• A method of communication initially described by Naomi Feil, a gerontological social worker
• Basic technique is to validate (through words, gestures) what the person with dementia says, regardless of accuracy or basis in fact, rather than correcting or re-orienting the person
• See Toseland et al. (1997) for an example of a group study of the effects of validation techniques on the behavior of individuals with dementia

Graphic and written cues

• Basic technique involves providing written factual information and/or familiar photographs to facilitate communication
• Capitalizes on recognition memory and the ability to read aloud, both of which may be relatively preserved in many individuals with Alzheimer's dementia
• Photographs and words can be incorporated into memory books/wallets, memo boards, and activity calendars
• See Hoerster, Hickey, and Bourgeois (2001) for an example of a study of the effects of memory wallet use on communication between caregivers and persons who have dementia

Montessori-based interventions

• Based on work done with children by Maria Montessori in the early 1900s and continuing today
• Basic technique is to create structured, stimulating activities that are appropriate to an individual's cognitive abilities, allowing engagement in tasks and the opportunity for social interaction
• Activities can be conducted individually with clients or in groups
• See Orsulic-Jeras, Schneider, and Camp (2000) for an example of a study of the effects of Montessori-based activities on the behavior of individuals with dementia

Spaced-retrieval training

• A memory training technique first applied by Cameron Camp (1989) for use with individuals with dementia
• Basic technique is to tell person with dementia a piece of information or show a particular behavior and then ask the person to recall it in response to a stimulus question systematically and over time
• The goal is to teach a functional piece of information or behavior that can be used in everyday situations (e.g., room number, caregiver name, transfer technique)
• See Hopper et al. (in press, 2005) for a systematic review of research related to spaced-retrieval training with individuals who have dementia

FOCUSED caregiver training program

• A caregiver communication training program in which each letter of the FOCUSED acronym stands for a specific communication technique (e.g., F = face-to-face communication)
• Designed to be used with both family and professional caregivers
• See Ripich and Ziol (1999) for an example of a group study on the effects of the program on caregiver knowledge and attitude toward communication with persons with dementia

Measuring progress as a result of treatment is relatively straightforward if goals are well-conceived, based on current assessment information, and relevant to both caregivers and clients. Barring any adverse events, the individual with dementia should make progress toward carefully selected goals. Frequency counts of the behaviors of interest, the amount of assistance or cues required to perform a task, the number and type of errors made during an activity, and the nature of caregiver communication behaviors are all appropriate outcome measures. Given the degenerative nature of irreversible dementia, global measures of cognitive function will generally not be sensitive to improvements in specific skills or behaviors that occur as a result of interventions.

SLPs working with this population need information on dementia, its effects on cognitive- communication function and appropriate assessment and treatment strategies.