Dementia

See the Treatment section of the Dementia Evidence Map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.

Most of the common dementia-associated diseases are progressive in nature, and goals will change over the course of treatment as communication needs and abilities change. SLPs have an ethical responsibility to provide services that maximize cognitive-communication functioning at all stages of the disease process.

Decisions about goals and treatment options are made in collaboration with the individual, family and caregivers, and other health professionals. See ASHA’s resources on IPE/IPP and person- and family-centered care. At the beginning and throughout the course of treatment, SLPs share information about dementia with the individual and their family/caregivers and provide family counseling and caregiver training.

Person-centered intervention focuses on maximizing the individual’s ability to participate in meaningful activities (e.g., Bourgeois, 2015; Chapey et al., 2000; Hickey, Khayum, & Bourgeois, 2018). SLPs consider the individual’s cultural and linguistic background, social history, present social context, communication needs, and personal desires when developing a treatment plan and formulating functional, personally relevant goals. It is imperative that SLPs ask the individual about his or her wishes for continued care over time, including feeding and swallowing directives. See ASHA’s resource on person- and family-centered care.

Consistent with the WHO (2001) framework, person-centered intervention is designed to

  • capitalize on strengths and address weaknesses related to underlying structures and functions that affect communication;
  • facilitate the individual’s activities and participation by helping the person acquire new skills and strategies; and  
  • modify contextual factors that serve as barriers and enhance facilitators of successful communication and participation, including development and use of appropriate accommodations in the environment.

Person-centered communication goals can focus on

  • linguistic processing in the context of various activities and settings;
  • executive or self-regulatory skills, such as goal setting, self-monitoring, and problem solving;
  • use of effective compensatory techniques and strategies for communicating;
  • use of alternative and/or augmentative methods to support communication; and
  • initiating or maintaining routines or roles in the individual’s living community.

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

Audiology services (e.g., hearing aids, hearing assistive technology) may be indicated for individuals with hearing loss.

Cultural and Linguistic Considerations

Treatment occurs in the language(s) used by the person with dementia, either by a bilingual SLP or through the use of trained interpreters, when necessary. See ASHA’s Practice Portal page on Bilingual Service Delivery.

Cultural influences and familial expectations may affect treatment decisions (Hinton, Fox, & Levkoff, 1999; Low et al., 2009; Parker, Young, & Rogers, 2010; Whitlatch & Feinberg, 2003; Williams & Harvey, 2013; Winslow & Flaskerud, 2009).

Cultural values, views of the aging process, and religious and spiritual beliefs relative to cognitive decline may influence a family’s decisions about therapeutic services. For example, families may not seek help, or they may delay seeking help until symptoms are beyond early or mild stages (Hart, Gallagher-Thompson, Davies, DiMinno, & Lessin, 1996; Pachana & Gallagher-Thomson, 2018; Regan, 2014). Families may fear the stigma of dementia, and this can also affect decisions about seeking help (Benbow & Jolley, 2012).

Dementia can have a significant impact on individuals in the LGBTQ community. For example, transgender individuals with dementia may experience periods of confusion about medical issues related to their natal gender (e.g., prostate cancer or uterine cancer), or about self-care and other daily tasks related to external gender changes (Age UK, 2013). Dementia may also make it challenging for LGBTQ individuals to manage disclosure—they may lose some ability to determine whom they share this information with (Barrett, Crameri, Lambourne, Latham, & Whyte, 2015).

Older LGBTQ individuals with dementia often experience a loss of identity, as a lack of cultural competence can lead to discrimination on the basis of age, sexuality and the stigma associated with dementia (McGovern, 2014). Care facilities should be sensitive to the needs of older LGBTQ patients and provide them with accommodations consistent with their expression (Voyzey, 2015).

See ASHA’s Practice Portal page on Cultural Competence

Caregiver Training

Family members and those who care for individuals with dementia are faced with challenges that can affect their own health and well-being (Gilhooly et al., 2016; Raggi, Tasca, Panerai, Neri, & Ferri, 2015; Snyder et al., 2015). Changes in communication functioning due to cognitive decline, together with behavioral changes, can have a significant impact on day-to-day interactions and can result in considerable frustration. SLPs work with families and caregivers to help them understand and manage these changes, minimize stress and frustration, and provide a supportive environment for the individual with dementia.

Training families and caregivers to use effective strategies that enhance communication may help them understand and repair communication breakdowns, engage in conversation more successfully, and improve quality of life for the individual with dementia (Zientz, Rackley, Chapman, Hopper, & Mahendra, 2007). 

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 general and specific treatments for persons with cognitive-communication disorders associated with dementia. Some treatment approaches are considered compensatory, and some are considered restorative. Compensatory treatment approaches focus on teaching the individual specific 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.

This list is not exhaustive, and inclusion of any specific treatment approach does not imply endorsement by ASHA. 

Assistive Technology

Assistive technology (AT) includes assistive, adaptive, and rehabilitative devices and services for individuals with disabilities. An AT 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.

Several commercially available and emerging assistive technologies (e.g., memory aids and navigational tools) may have applications to dementia care (Bharucha et al., 2009). Selection of specific AT devices and systems will depend on the stage of dementia; individuals in the early stages of the disease will most likely be able to use a wider range of devices and systems than will individuals in the later stages (e.g., Collins, 2018).

Hearing Assistive Technology Systems (HATS) can be used to enhance face-to-face communication. HATS are available for individuals with hearing loss who currently use hearing aids or have cochlear implants and for individuals with untreated hearing loss. HATS include FM systems, induction loops, and personal amplification devices. See ASHA’s resource on hearing assistive technology. HATS may be appropriate for individuals with dementia who have hearing loss. 

Cognitive Stimulation Therapy

Cognitive stimulation therapy (CST) is a group treatment for individuals with mild to moderate dementia. CST uses theme-based, mentally stimulating, relevant activities aimed at improving cognitive function (e.g., thinking, concentration, and memory). Individuals are actively engaged in optimal learning environments—typically, in a small-group setting (e.g., Aguirre, Woods, Spector, & Orrell, 2013; Woods, Aguirre, Spector, & Orrell, 2012). 

Computer-Based Cognitive Interventions

Computer-based treatment involves the use of computer technology (e.g., touchscreen tablets) and/or software programs to increase mental activity and enhance cognitive functioning, including processing speed, attention, and working memory (e.g., Barnes et al., 2009). Some available programs generate data about the individual’s progress on specific tasks; these data can be used in clinical documentation.

In addition to using programs to target specific cognitive functions, computers can also be used to perform relevant, day-to-day tasks such as emailing friends and keeping track of appointments. 

Environmental Modifications

Environmental modifications are changes or adaptations to the environment to improve overall functioning in individuals with dementia. They are designed to support communication needs and abilities by reducing barriers and minimizing the impact of impaired body function.

Modifications are aimed at enhancing the following aspects of the environment:

  • Cognitive—includes using personalized living spaces to aid memory and orientation, labels, signs that incorporate text and simple graphics, step-by-step sequencing cards to guide activities, cues to support “way-finding” and orientation, and verbal instructions
  • Visual—includes reducing glare, improving lighting, reducing visual clutter, arranging items (e.g., furniture and personal items) in an organized way, and providing a clear line of sight to items and locations (e.g., bathroom)
  • Auditory—includes minimizing background noise (e.g., TV, radio) when possible; improving audibility by reducing noise reverberation (e.g., by using rugs and drapery); and using amplification devices when needed (Brush, Sanford, Fleder, Bruce, & Calkins, 2011)

Assessing the individual’s performance in relevant settings (e.g., home, social setting, clinical setting) is essential for identifying relevant environmental barriers and facilitators and potential modifications (Brush et al., 2011; Brush, Calkins, Bruce & Sanford, 2012).

External Memory Aids

External memory aids are aimed at helping individuals with memory problems in their day-to-day activities. They help compensate for memory deficits, maximize independence, improve conversation, reduce anxiety, and decrease responsive behaviors such as repetitive questioning (Bourgeois, 1994; Hickey & Bourgeois, 2018).

External memory aids include enhancements to cognitive aspects of the environment (see the “Environmental Modifications” section of this document), checklists, daily planners, calendars, programmable watches, pill reminders, smartphones, and recorded messages (e.g., voicemails). External aids such as memory books, memory wallets, and communication cards can also be used to help an individual retrieve personal information for stimulating and maintaining conversation (e.g., Bourgeois 1990, 1992a, 1992b, 2013; Hickey & Bourgeois, 2018).   

External memory aids in the form of tangible prompts (e.g., photographs, familiar items, and music from the past) are used in reminiscence therapy to stimulate conversations about past events, activities, and experiences. The customized nature and individual focus of reminiscence therapy make it well suited for individuals from diverse backgrounds (Harris, 1997).

Montessori for Aging and Dementia

Montessori for Aging and Dementia is a person-centered approach based on the work of Dr. Maria Montessori. This approach focuses on the abilities, needs, interests, and strengths of elders with dementia in a supportive environment. It empowers individuals to engage in meaningful activities throughout the course of their lives (see, e.g., Bourgeois, Brush, Elliot, & Kelly, 2015; Brush & Norris, 2017; Elliot, 2015).

Characteristics of a typical Montessori classroom (e.g., freedom, structure and order, reality and nature, beauty and atmosphere, and specialized materials) are integrated into the eldercare setting. The environment is structured to support the individual by placing needed memory, visual, auditory, tactile, and olfactory cues in the environment. For example, high-contrast signs can be used to compensate for memory deficits and to encourage engagement with environment. A sign saying, “Please water the flowers,” might be placed next to potted plants and a watering can.

The Montessori approach encourages individuals with dementia to continue to care for themselves as independently as possible and provides opportunities and supports to care for others (e.g., reading to another individual with vision impairment). 

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 voice recordings of the individual’s close relatives. 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). 

Spaced Retrieval (SR)

Spaced Retrieval (SR) is a technique for learning and storing information so that it can be easily accessed. SR teaches new memory associations using the principles of classical conditioning and taking advantage of preserved implicit (unconscious or automatic) memory. For example, a lead question prompts a previously relevant response—a new, functional association between the question and the response is established using systematic spaced practice (i.e., practice over increasingly longer intervals of time) and the principles of errorless learning (Benigas, Brush, & Elliot, 2016; Brush & Camp, 1998). Errorless learning is a strategy that eliminates errors as much as possible by providing prompts and cues immediately following instruction.

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, provide opportunities for the individual to communicate feelings, promote contentment, and lessen negative behaviors. Using validation therapy, the clinician tries to communicate with the individual by acknowledging the feelings that underlie their behavior and confused speech (Feil, 1982; Hitch, 1994; Mitchell, 1987; Neal & Briggs, 2003). 

Eating and Swallowing Interventions

Individuals progressing through the stages of dementia may experience increasing difficulties surrounding mealtime, including behavioral challenges (e.g., forgetting to eat, wandering); eating problems (difficulty using utensils or self-feeding); and swallowing disorders (dysphagia; Aselage, 2010; Watson & Green, 2006). For example, individuals with moderately severe cognitive decline may have difficulty manipulating a knife; individuals with severe cognitive decline may have difficulty 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).

These problems can have an impact on the health of an individual. Decisions regarding treatment should take into consideration the potential health risks associated with eating and swallowing problems, along with the individual’s dignity and quality of life throughout the course of the disease (Hickey, Cleary, Coulter, & Bourgeois, 2018).

Depending on the needs of the individual, goals may focus on one or more of the following:

  • Improving the ability to eat and swallow safely
  • Increasing intake to improve nutrition and hydration
  • Encouraging engagement and participation in the mealtime experience (Hickey, Cleary, Coulter, & Bourgeois, 2018).

Goal selection is person centered. It considers the wishes of the individual with dementia and their family (e.g., cultural food choices, family rituals at mealtime, and religious beliefs) and involves input from an interdisciplinary team of professionals (e.g., Beckley, 2017). See ASHA’s resources on person- and family-centered care and IPE/IPP. See also ASHA’s Practice Portal page on Adult Dysphagia.

Interventions may include the following:

  • Environmental modifications such as
    • home-like or naturalistic settings (Aselage & Amella, 2010; Brush, Meehan, & Calkins, 2002; Brush et al., 2011);
    • adaptive seating to improve posture (Liu et al., 2016);
    • verbal prompts and cues to increase food intake (Aselage, Amella, & Watson, 2011; Liu et al., 2016); and
    • increased lighting and decreased visual and auditory distractions (see, e.g., Behrman, Chouliaras, & Ebmeier, 2014; Calkins & Brush, 2003).
  • Diet modifications such as
    • altering texture, temperature, or taste of foods to facilitate safety and ease of swallowing and to improve intake (see, e.g., Douglas & Lawrence, 2015; Keller, Chambers, Niezgoda, & Duizer, 2012; Yen, 1996) and
    • including high-energy, nutrition-rich foods to ensure adequate nourishment (see, e.g., Spindler, 2002).

Other interventions include strategies to maximize independence and safety (e.g., shopping lists, weekly meal planners, and written cues to sequence mealtime activities or to identify steps for using safe-swallow strategies).

For a comprehensive discussion of eating and swallowing interventions for individuals with dementia, see Hickey, Cleary, Coulter, & Bourgeois, 2018.

Tube Feeding

Tube feeding for supplemental or alternative intake is sometimes considered for a short or extended period of time for individuals with late-stage dementia. The decision to implement tube feeding is complicated. It should take into account the potential complications of tube feeding and the individual’s quality of life.

Decisions about tube feeding should consider input from the team and should reflect the wishes of the individual and his or her family. Ideally, a discussion about the potential use of tube feeding in later stages of dementia should take place when the individual is cognitively able to communicate his or her wishes about end-of-life options (see, e.g., American Geriatrics Society [AGS], 2014, and Hickey, Cleary, Coulter, & Bourgeois, 2018, for further discussion). 

Treatment For Hearing Loss

The presence of dementia should not preclude fitting with a hearing aid; however, ongoing support may be necessary to ensure regular hearing aid use (Lewsen & Cashman, 1997). Responsive behaviors (e.g., repeating questions, making negative statements, forgetting, demonstrating restlessness, pacing, and “hearing things”) may be improved with the use of amplification (Palmer, Adams, Bourgeois, 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 the 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 hearing aids, audiologists may also recommend various inexpensive, low-risk HATS options (e.g., low-cost one-on-one amplification devices, devices to make phones louder, and closed-caption TV) for improving communication.

Audiologists also 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.

See ASHA’s resource on hearing assistive technology. See also ASHA’s Practice Portal page on Hearing Aids for Adults.

End-of-Life Issues

The pattern of functional decline in individuals at the end of life varies. For individuals with 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 facing the individual and their family members.

The goal of intervention with individuals who are nearing the end of life is facilitative or palliative rather than rehabilitative. The expected outcome of intervention is not necessarily to improve abilities but to help the individual maintain dignity and quality of life.

Cognitive decline may be significant at this stage of dementia, making it difficult for the individual to make decisions about their care or to communicate their wishes (Livingston et al., 2017). The SLP’s role is essential in helping the individual communicate their preferences about how they would like to receive care and how they want to spend their time.

Early on and throughout the course of the dementia, SLPs can discuss and document the individual’s wishes and help develop strategies that allow the individual to express wants and needs more effectively. They can also help the individual communicate last wishes to the family and possibly resolve long-standing issues (e.g., making peace with family members or asking for forgiveness).

The wishes of the individual and his or her 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 is best clinically may not always be best for the individual’s quality of life. JCAHO's 2004–2005 Ethics, Rights, and Responsibilities Standards address this issue in Standard RI.2.80 (JCAHO, 2004).

Cultural Considerations

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; however, they 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 ASHA’s resources on end-of-life issues in speech-language pathology and end-of-life resources and references.

Service Delivery

See the Service Delivery section of the Dementia Evidence Map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.

In addition to determining the optimal, person-centered dementia treatment, audiologists and SLPs consider other service delivery variables—including format, provider, dosage, timing, and setting—that may affect treatment outcomes.

  • Format: The structure of the treatment session (e.g., group, individual, in consult with the family).
  • Provider: The person providing the treatment (e.g., SLP, trained volunteer, caregiver).
  • Dosage: The frequency, intensity, and duration of service.
  • Timing: The timing of intervention relative to the onset of dementia.
  • Setting: The location of treatment (e.g., home, assisted living facility, nursing facility, community-based setting).

Group treatment can be used as a format to apply learned strategies and to practice communication in natural conversational contexts.

Technology can be incorporated into the delivery of services for dementia, including computer-based treatment programs and the use of telepractice as a format for delivering face-to-face services remotely. See ASHA’s Practice Portal page on Telepractice.

Treatment extenders such as family members, volunteers, and community members can be trained to encourage the use of communication strategies that were learned in structured treatment sessions. In this way, treatment extenders provide practice in the home and in the community.

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.