Dementia

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 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, linguistic, and environmental influences that have an impact on functioning.

The assessment is sensitive to cultural and linguistic diversity and should occur in the language(s) used by the person with dementia. See ASHA’s Practice Portal pages on Cultural Competence and Bilingual Service Delivery.

SLPs often conduct assessments in collaboration with clinical neuropsychologists. See ASHA’s resources on collaboration and teaming as well as evaluating and treating communication and cognitive disorders – approaches to referral and collaboration for speech-language pathology and clinical neuropsychology.

Screening

Screening for cognitive impairment is conducted for individuals with any condition that increases the risk of cognitive-communication problems. The screening is conducted by an SLP, audiologist, or other member of the interdisciplinary care team working with the individual. See Scope of Practice in Audiology (ASHA, 2018) and Scope of Practice in Speech-Language Pathology (ASHA, 2016b).

Standardized instruments with demonstrated reliability for dementia screening 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 early dementia (Bayles & Tomoeda, 1993; Rabin et al., 2009; Takayama, 2010; Wechsler, 2009). If screening reveals cognitive impairment, the individual is referred to an SLP for a comprehensive evaluation of communicative function.

Prior to screening for cognitive-communication disorders, it is important to consider the impact of sensory impairment (hearing and vision), depression, and current medications on cognitive functioning.

Hearing Loss

Hearing loss is a common consequence of aging, and many older adults have both hearing loss and cognitive impairment. Together, these losses can affect communication, social participation, and quality of life (Pichora-Fuller, Dupuis, Reed, & Lemke, 2013). Therefore, 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.    

Audiometric hearing screening and otoscopic inspection for impacted cerumen are to be conducted prior to cognitive-communication screening. See Scope of Practice in Speech-Language Pathology (ASHA, 2016b) and ASHA’s Practice Portal page on Adult Hearing Screening.

If an individual has a diagnosed hearing loss and wears hearing aids, the clinician inspects the aids to ensure that they are in working order, and the individual should wear them during screening. The use of assistive listening technology should be employed when hearing aids are not being used. See ASHA’s Practice Portal pages on Hearing Loss - Beyond Early Childhood and Hearing Aids for Adults.

If the individual fails the hearing screening, a referral is made to an audiologist for a comprehensive audiologic assessment. 

Visual Impairment

If visual deficits are suspected, the individual is referred for vision testing prior to completing cognitive-communication screening. Prescription eyeglasses, as needed, are to be worn during screening, and adequate lighting is to be 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—the concurrent use of several medications—is common among older adults who have multiple medical conditions, and some medications may exacerbate cognitive problems. Questions about the effects of medication use on cognitive-communication functioning can be answered by a pharmacist knowledgeable in geriatric pharmacy. 

Comprehensive Assessment

A comprehensive assessment includes an assessment of language and communication. It may also include an assessment of swallowing and a complete audiologic assessment. 

Consistent with the World Health Organization's (WHO’s) International Classification of Functioning, Disability and Health (ICF) framework (ASHA, 2016a; WHO, 2001), comprehensive assessment is conducted to identify and describe

  • impairments in body structure and function, including factors that affect communication performance (e.g., cognition, language, and social/behavioral as well as  swallowing, when affected);
  • co-morbid deficits or health conditions such as hearing loss or depression;
  • limitations in activity and participation, including limitations in functional communication and interpersonal interactions;
  • contextual (environmental and personal) factors that serve as barriers to, or facilitators of, successful communication and participation in ideal settings, everyday contexts, and employment settings; and
  • the impact of impairments on quality of life for the individual and his or her family and community.

See ASHA’s Person-Centered Focus on Function: Dementia [PDF] for an example of assessment data consistent with ICF.

Assessments 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 (e.g., yearly) reevaluations are essential to adjust care plans to meet the changing needs of the individual.  

SLP Assessment

The SLP determines the most appropriate assessment protocol based on the stage of dementia and the individual’s communication needs and wishes. The information gathered during the assessment will guide the development of person-centered intervention focused on maximizing the individual’s ability to participate in meaningful activities (e.g., Bourgeois, 2015; Chapey et al., 2000; Hickey, Khayum, & Bourgeois, 2018). See ASHA’s resource on person- and family-centered care.

The protocol may include standardized and nonstandardized assessment tools and a variety of other data sources, including clinical observations in the home or long-term care setting. These observations provide personally relevant information about the individual’s cognitive-communication strengths and needs in everyday situations. Conversations with the individual and his or her family and caregivers can help identify the individual’s personal goals for continued, meaningful life participation. See ASHA’s resource on assessment tools, techniques, and data sources

A number of assessment tools have been standardized on individuals with dementia. They can be used to evaluate language comprehension and expression and the integrity of working, declarative, and procedural memory systems. The severity of dementia needs to be taken into consideration when selecting tests. Some tests are too difficult for individuals with severe dementia and do not yield useful information.   

When selecting standardized assessments, the clinician considers the cultural and linguistic background of the client and, when available, uses tests that have normative samples of culturally and ethnically diverse groups. Standard scores should not be reported if the normative sample is not representative of the individual being assessed.

Audiologic Assessment

Traditional behavioral tests of hearing (e.g., pure-tone and speech audiometry) are generally successful in the early stages of dementia, although modifications may be needed. These include simplifying directions, using pulse tones, slowing presentation of speech stimuli, providing reminders to respond, and allowing a “yes” response instead of raising a finger or pressing a button.

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). 

Typical Components of the Comprehensive Assessment

Case History
  • Medical status and medical history
  • Review of auditory, visual, motor, cognitive, and emotional status
  • Demographic information (e.g., educational level, marital status, occupation)
  • Current living arrangements and available supports
  • Language(s) spoken
Interview with Individual
  • Report of cognitive changes (e.g., memory loss, forgetfulness, disorientation, getting lost)
  • Impact of changes on functional communication and life participation
  • Contexts of concern (e.g., social interactions, work activities)
  • Language(s) used in contexts of concern
  • Goals for continued functional communication and life participation
Interview with Family/caregivers
  • Observations of cognitive changes
  • Impact of changes on individual’s functional communication and ability to participate fully in everyday activities
  • Impact of changes on individual’s safety and safety awareness
  • Contexts of concern (e.g., social interactions, family discussions and decision making)
Cognitive-communication
  • Observation of the individual’s communication and level of participation during everyday activities (e.g., mealtime; conversations with friends, family, and caregivers)
  • Assessment of ability to process various types of information (e.g., attend to, perceive, organize, and remember verbal and nonverbal information) under ideal conditions and in the context of various activities and settings
  • Assessment of executive or self-regulatory control (e.g., ability to set goals, plan, initiate and inhibit, self-monitor and self-evaluate, solve problems, and think and act strategically)
  • Analysis of the cognitive and communication demands of relevant social, academic, and/or vocational tasks and identification of possible task modifications to facilitate performance
  • Identification of the individual’s potential for using effective compensatory strategies and identification of motivational barriers and facilitators to using these strategies
  • Evaluation of current communication and support competencies of relevant people in the individual’s life
Assessment of Swallowing
Clinical Assessment
  • Involves food and liquid trials with a variety of temperatures, textures, tastes, postures, and strategies and consideration for the individual’s food preferences
  • Includes evaluation of the
    • oral mechanism;
    • ability to comprehend and use compensatory strategies;
    • oral preparatory, oral, pharyngeal, and esophageal phases of swallowing;
    • recognition of food and utensils;
    • impact of the appearance of food, lighting, and distractions on swallowing function;
    • potential impact of medications on swallowing function; and
    • influence of cognitive factors on feeding and swallowing. 
Instrumental Assessment
  • Conducted when indicated and as tolerated by the individual
  • Used to determine swallowing safety and identify effective treatment techniques or strategies
  • Can provide information about the oral and pharyngeal bolus transit, airway protection, the impact of bolus texture and size, and appropriate pacing (Easterling & Robbins, 2008)

See the Assessment section of ASHA’s Practice Portal page on Adult Dysphagia for more information.

Audiologic Assessment
  • Otoscopic examination
  • Immittance testing to assess middle ear function
  • Pure-tone air and bone conduction to determine presence and type of hearing loss
  • Otoacoustic emissions testing to assess outer hair cell function
  • Word recognition (discrimination)
  • Speech recognition (closed or open set, depending on age)

See ASHA’s Practice Portal page on Permanent Childhood Hearing Loss for information about full audiologic assessment conducted by an audiologist.

Assessment Results

The comprehensive assessment may result in

  • diagnosis of a cognitive-communication and/or swallowing disorder;
  • diagnosis of hearing loss;
  • clinical description of the characteristics of the disorder(s);
  • identification of the individual’s communication needs and his or her goals for life participation;
  • identification of facilitators and barriers to life participation;
  • recommendations for intervention and support; and
  • referral for other assessments or services. 

Assessment in Long-Term Care Communities

The Omnibus Budget Reconciliation Act (1987) mandates evaluation of the physical and psychological status of residents in long-term care communities 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 individuals living in long-term care communities.

Content Disclaimer: The Practice Portal, ASHA policy documents, and guidelines contain information for use in all settings; however, members must consider all applicable local, state and federal requirements when applying the information in their specific work setting.