See the Dementia Evidence Map for summaries of the available research on this topic.
Dementia is a clinical syndrome resulting from medical disease that causes abnormal brain changes. It is characterized by a progressive decline in memory and other cognitive domains that are severe enough to interfere with daily living and independent functioning. Dementia may result from a variety of medical diseases and may be due to more than one disease process. See the National Institutes of Health’s resource on understanding different types of dementia for further information.
This definition is consistent with the diagnostic category, major neurocognitive disorder (NCD), as defined in the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; American Psychiatric Association [APA], 2013). The diagnostic criteria for major NCD are as follows:
The diagnosis of dementia is made by a medical team. Audiologists and speech-language pathologists (SLP) are important members of interprofessional teams that treat individuals with dementia and can provide vital information about cognitive-communication, language, and feeding/eating/swallowing skills that can contribute to appropriate diagnosis. See ASHA’s resource on interprofessional education/interprofessional practice (IPE/IPP).
Most dementias are associated with neuropathology that includes diffuse atrophy of cortical and subcortical structures; disruption of neural pathways; and the abnormal accumulation of amyloid beta, tau, and other proteins resulting in plaques and tangles (Schneider, 2022).
Cognitive and behavioral symptoms of dementia are differentiated from those associated with typical aging as well as from those associated with temporary or treatable conditions, including the following:
Unlike these conditions, the symptoms associated with dementia continue to progress in severity until death (see, e.g., Bourgeois & Hickey, 2009).
Cognitive changes caused by dementia may impact communication and may cause challenging behaviors (e.g., paranoia, hallucinations, and repetitiousness) and other responsive behaviors (atypical behaviors in response to stimuli that are perceived as stressors in the environment), such as wandering, restlessness, or calling out. SLPs can help caregivers determine the communication intent of these behaviors (Lanzi et al., 2021; Yous et al., 2019).
Mild cognitive impairment (MCI), also known as mild neurocognitive disorder (mild NCD), is a clinical syndrome that is characterized by a modest decline in one or more cognitive domains. MCI is often referred to as an early stage of cognitive impairment that is in between typical aging and dementia; however, MCI does not always progress to dementia (Petersen et al., 2014). Early identification of MCI may enable the use of cognitive interventions to slow the progression of decline (Huckans et al., 2013; Qualls, 2005; Tsolaki et al., 2011). See the discussion on modifiable risk factors in the Risk Factors section of this Practice Portal page.
This definition of MCI is consistent with the diagnostic category, mild NCD, as defined in the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; APA, 2013). The clinical criteria for diagnosing mild NCD are as follows:
See ASHA’s Mild Cognitive Impairment Evidence Map for summaries of the available evidence on this topic.
Early-onset dementia, also known as “young-onset dementia,” refers to dementia that occurs before the age of 65 years. Differential diagnosis of early-onset dementia is complicated by the fact that symptoms may be more variable in younger patients than in elderly patients due to different etiologies (Fadil et al., 2009; Masellis et al., 2013; McMurtray et al., 2006; Rossor et al., 2010); lack of awareness about the condition, even among health care professionals (Jefferies & Agrawal, 2009); and misdiagnosis (van Vliet et al., 2011). Some causes of dementia symptoms could be reversible if detected early and the underlying medical conditions, such as infections and metabolic toxins, are treated. Therefore, early detection and accurate diagnosis are crucial (Fadil et al., 2009).
Incidence refers to the number of new cases of a disorder identified in a specified time period.
Prevalence refers to the number of people who are living with the disorder in a given time period.
Worldwide, it is estimated that over 55 million people are living with dementia, with an average of nearly 10 million new cases every year (World Health Organization, 2023). Dementia is less common in individuals under the age of 65 years, with approximately 3.9 million individuals living with early-onset dementia (Hendricks et al., 2022). The estimated incidence of mild cognitive impairment increases with increased age. The estimated number of new diagnoses of mild cognitive impairment each year per every 1,000 individuals is approximately 22.5 for individuals aged 75–79 years, 60.1 for individuals aged 80–84 years, and 60.1 for individuals aged 85 years or older (Gillis et al., 2019).
Estimates of the incidence and prevalence of the specific types of dementia seen within commonly associated neurodegenerative diseases are as follows:
Alzheimer’s disease: Within the United States, approximately 6.7 million people over the age of 65 years are living with Alzheimer’s dementia (Alzheimer’s Association, 2023a).
Frontotemporal dementia: Worldwide, approximately 15–22 of every 100,000 individuals are living with frontotemporal dementia (Knopman & Roberts, 2011). Approximately 2.7–4.1 of every 100,000 individuals receive a new diagnosis each year (Onyike & Diehl-Schmid, 2013). Within the United States, an estimated 50,000–60,000 people are currently living with the two types of frontotemporal dementia: primary progressive aphasia and behavioral variant frontotemporal dementia (Alzheimer’s Association, 2023c).
Huntington’s disease: Within the United States, approximately 32% of Medicare recipients who were diagnosed with Huntington’s disease have a diagnosis of dementia (Nguyen et al., 2022). Huntington’s disease is estimated to impact 13.1–15.2 of every 100,000 individuals (Exuzides et al., 2022).
Lewy body dementia: Within the United States, over 1 million people are living with Lewy body dementia (National Institutes of Health, 2019). Based on statistics reported from Medicare beneficiaries, it is estimated that 110–120 of every 100,000 individuals are diagnosed with Lewy body dementia in the United States each year (Desai et al., 2022).
Parkinson’s disease: Approximately 24%–31% of individuals with Parkinson’s disease have dementia (Aarsland et al., 2005). Based upon projected estimates by Yang et al. (2020), approximately 290,000–375,100 individuals are currently living with Parkinson’s disease–associated dementia.
Vascular dementia: Worldwide, it is estimated that 14.9 of every 100,000 people are living with vascular dementia (Hendriks et al., 2021).
Of note, individuals may have mixed dementia, or dementia due to multiple contributing disease processes. Although studies suggest that the prevalence of mixed dementia is higher than previously recognized, no exact estimates of its incidence and prevalence currently exist; however, the likelihood of having mixed dementia increases with age, with the highest prevalence in individuals aged 85 years and older (Alzheimer’s Association, 2022).
The proportion of older adults with dementia declined from 2011 to 2019 (Freedman & Cornman 2023). It is suspected that reasons for this decline include increased efficacy of treatment for the risk factors associated with dementia and higher cognitive reserves (i.e., higher education levels) seen in successive birth cohorts (Zissimopoulos et al., 2018). Despite this trend, it is expected that the absolute number of people affected by dementia will increase over time due to increased life expectancy and population growth (GBD 2019 Dementia Forecasting Collaborators, 2022). This is mainly due to the fact that age is the greatest risk factor of dementia, with prevalence doubling every 5 years after age 65 years (Fiest et al., 2016).
The signs and symptoms of dementia differ depending on the cause and the stage. Although late-stage signs and symptoms are similar across etiologies, early-stage symptoms can vary considerably. For example, individuals with frontotemporal dementia may develop primary progressive aphasia, a gradual loss of language function with relatively well-preserved memory, while individuals with Alzheimer’s disease may experience significant changes in memory (Hegde, 2006). See the National Institutes of Health’s resource on understanding different types of dementia for further information.
In general, individuals with dementia experience a gradual loss of cognitive and/or motor functions. As the disease progresses, early symptoms intensify, eventually affecting the ability to communicate effectively and function independently.
Cognitive decline is a core feature in all types of dementia and may result in cognitive-communication deficits and/or reduced communicative participation. However, not every person with dementia will experience deficits in all areas listed below, and symptoms can vary depending on the underlying neuropathology, the stage of the disease, and individual differences. Individuals with mild cognitive impairment or dementia experience a decline in one or more of the following domains.
People with dementia may experience lack of orientation to
People who are multilingual may make errors in selecting and maintaining appropriate language during conversation (Friedland & Miller, 1999) and may use only their first acquired language (Kokorelias et al., 2017; Mendez et al., 1999).
Behavioral and psychosocial symptoms are common in dementia (see, e.g., Müller-Spahn, 2003). Individuals with dementia often exhibit responsive behaviors—atypical behaviors in response to stimuli that they may perceive as stressors in the environment. Responsive behaviors are often perceived or labeled as aggressive behavior by the care partners. These behaviors may occur as a reaction to unmet needs (e.g., pain), responses to the environment (e.g., overcrowding), expressions of psychosocial needs (e.g., depression), and resistance to care partners and other individuals (Yous et al., 2019; Song et al., 2019).
Behavioral and psychosocial changes can lead to frustration and misunderstanding between the individual with dementia and their care partner. It is important for care partners to consider why the behavior is occurring (e.g., to communicate a message) and to explore ways to facilitate better communication (e.g., react differently, be understanding, modify/adapt to the environment, focus on a different activity).
See Behaviors: How to Respond When Dementia Causes Unpredictable Behaviors [PDF] from the Alzheimer’s Association for more information.
Cognitive changes, such as those that occur in dementia, can significantly impact safe and effective swallowing (Winchester & Winchester, 2015). Swallowing function changes as part of normal aging (Namasivayam-MacDonald et al., 2018); however, these changes may appear sooner or be more pronounced in individuals with dementia (Groher, 2015).
It is estimated that 32.7%–86.6% of individuals with dementia experience swallowing impairment, with increased likelihood of dysphagia as disease course progresses (DeStefano et al., 2020; Espinosa-Val et al., 2020; Michel et al., 2018).
Cognitive and behavioral changes associated with dementia can also have an impact on eating. Individuals may progressively
Eating and swallowing difficulties may increase the risk of choking and aspiration pneumonia (Bourgeois & Hickey, 2009) and may eventually result in malnutrition, dehydration, weight loss (Hanson et al., 2013; Jensen et al., 2013), overall compromised general health, and mortality.
Alzheimer’s disease is the most common cause of dementia, accounting for an estimated 60%–80% of all cases (Alzheimer’s Association, 2023b).
The remaining cases are accounted for by vascular dementia, Lewy body dementia, dementia associated with other neurodegenerative conditions such as Parkinson’s disease and Huntington’s disease, frontotemporal dementia, and mixed dementia types (e.g., Alzheimer’s disease with Lewy body pathology and Alzheimer’s disease with vascular pathology; Livingston et al., 2017; Mahendra & Hopper, 2013; Plassman et al., 2007). See the National Institutes of Health’s resource on understanding different types of dementia for further information.
Other conditions that may result in dementia due to progressive changes in brain function include
Modifiable risk factors for dementia are those that, if managed, can potentially prevent or delay the onset of some cases of dementia. Neuroprotective behavior, either prior to the onset of dementia or during the onset of dementia, may delay or decrease the severity of dementia symptoms (De la Rosa et al., 2020; Fratiglioni et al., 2020).
Livingston et al. (2020) discuss some modifiable risk factors for dementia, including the following:
Audiologists and SLPs can play a primary role in mitigating these risk factors through hearing loss prevention and remediation as well as interventions to stimulate cognition and enhance communication and social participation (Lanzi et al., 2021). It is important for clinicians to provide education and counseling to help support older adults in mitigating their risk of further decline.
Cognitive reserve refers to the individual differences in the way individuals process tasks due to differences in brain anatomy and/or life experiences. Cognitive reserve accounts for the observation that there is not always a direct relationship between the degree of brain damage or pathology and the resulting deficit, and individuals with higher cognitive reserves may be able to withstand more advanced disease progression before outwardly demonstrating significant cognitive impairment (Stern, 2009). Factors that may contribute to cognitive reserve, and thus have a neuroprotective effect, include engaging in complex occupations, participating in cognitively stimulating leisure activities, and obtaining higher levels of education (Opdebeeck et al., 2016; Stern, 2009). Additionally, lifelong multilingualism may contribute to cognitive reserve and, therefore, be considered neuroprotective behavior (Guzmán-Vélez & Tranel, 2015).
Nonmodifiable risk factors are those that cannot be changed or modified by the individual. They include age and heredity.
Age is the greatest nonmodifiable risk factor for dementia. Every 5 years after age 65, the number of individuals with Alzheimer’s disease doubles; about one third of people over age 85 have the disease (National Institute on Aging, 2017).
Heredity can play a part in dementia risk, and the risk of acquiring dementia is higher if an individual has a first-order relative with the disease (Green et al., 2002; Lovestone, 1999; Wolters et al., 2017). This risk may be linked to inheritance of the apolipoprotein E (ApoE) gene (e.g., Green et al., 2002; Lovestone, 1999) or to unexplained hereditary causes (Wolters et al., 2017). Because of the known heredity nature of dementia, it is important to obtain a family history during chart review and interview with patients.
The World Health Organization (WHO) describes social determinants of health as the nonmedical factors and forces of someone’s daily life that impact their health outcomes. SLPs should consider social determinants of health when determining what risk factors are modifiable and nonmodifiable. For example, education level may not be realistically modified, because it is heavily influenced by a person’s environment and socioeconomic status.
For further information, see ASHA’s resource on social determinants of health and the Centers for Disease Control and Prevention’s resource on social determinants of health and Alzheimer’s disease and related dementias.
On a global scale, hearing loss accounts for the largest proportion of potentially modifiable risk factors for dementia. After adjusting for other risk factors (e.g., education, diabetes, cardiovascular factors), hearing loss is related to, but has not been determined to cause, an increased risk of dementia (Deal et al., 2017; Lin et al., 2011). The signs and symptoms of both dementia and hearing loss are closely related, and audiologists and SLPs should be aware that these two conditions may occur simultaneously or independently. For individuals with suspected cognitive decline without a confirmed history of hearing loss, hearing screening and subsequent referrals to audiologists for full hearing evaluations should be considered. For individuals with a confirmed history of hearing loss, regular reevaluation can help ensure that appropriate treatment plans can be implemented to maximize hearing access. A referral to the patient’s primary medical professional for evaluation and management is appropriate if an audiologist or an SLP suspects dementia.
Individuals with baseline hearing loss were found to have greater rates of cognitive decline over time than individuals with normal hearing (Lin et al., 2013). This cognitive degradation can be linked to a greater workload for the brain to process speech when the signal is diluted or distorted due to a hearing impairment. Ray et al. (2019) suggest that “the excessive cognitive load leads to changes in brain structure and further neurodegeneration.” Lin and Albert (2014) noted that older adults with hearing loss showed “reduced volume in the auditory cortex” and “accelerated brain atrophy in whole brain and regional volumes concentrated in the right temporal lobe.”
Several hypotheses have been proposed to account for the association between hearing loss and dementia. They include the following:
It is possible that the mechanism proposed by each of these hypotheses is not mutually exclusive and that each contributes individually or in combination to increase the risk of dementia. Further investigation is needed to clarify the relationship between hearing loss and dementia (Loughrey et al., 2018; Thomson et al., 2017).
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, 2016).
Appropriate roles for SLPs include the following:
As indicated in the ASHA Code of Ethics (ASHA, 2023), SLPs who serve this population should be specifically educated and appropriately trained to do so. Given the impact of cognitive decline on communication and swallowing, practitioners who serve individuals with dementia require knowledge and skills in all these areas, including specific knowledge of cognitive-communication disorders and dysphagia associated with dementia.
Most of the common dementia-associated diseases are progressive, 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.
Audiologists play a critical role in the assessment and care of individuals with dementia. The professional roles and activities in audiology include clinical services related to hearing loss (assessment, diagnosis, planning, and treatment); prevention and advocacy; and education, administration, and research. See ASHA’s Scope of Practice in Audiology (ASHA, 2018).
Appropriate roles for audiologists include the following:
As indicated in the ASHA Code of Ethics (ASHA, 2023), audiologists who serve this population should be specifically educated and appropriately trained to do so. Given the relationship between hearing and dementia, audiologists who serve individuals with dementia require knowledge and skills in both areas as well as knowledge of cognitive-communication problems associated with dementia.
Most of the common dementia-associated diseases are progressive, and audiologists have an ethical responsibility to provide appropriate services that will benefit the individual and maximize communication function at all stages of the disease process.
See the Assessment section of the Dementia Evidence Map for pertinent scientific evidence, expert opinion, and client/care partner perspective.
SLPs assess cognitive-communication deficits and dysphagia related to dementia while also considering cultural, linguistic, and environmental influences. Audiologists perform audiometric assessment, if deemed necessary following potential SLP-performed hearing screening, to rule out or identify hearing loss as a contributing factor to demonstrated cognitive degradation.
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 Responsiveness 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 for cognitive-communication and swallowing impairments may be conducted for individuals with any condition that increases the risk of mild cognitive impairment or dementia. The screening may be conducted by an SLP or other trained member of the interprofessional care team working with the individual. See Scope of Practice in Audiology (ASHA, 2018) and Scope of Practice in Speech-Language Pathology (ASHA, 2016).
Standardized instruments with demonstrated reliability regarding screening for dementia are available; however, it is important to note that a screening involves more than the use of a single tool (Lanzi et al., 2021). These instruments typically include brief assessments of 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).
Screening protocols may also briefly assess other cognitive domains at a surface level. In addition, patient- or care partner–reported outcome measures may be valuable tools to capture the individual’s or family’s perspective on cognition and functional status, which might not be captured by other screening tools (Cohen & Hula, 2020). If screening reveals cognitive impairment, the individual may be referred to an SLP for a comprehensive evaluation.
Prior to screening for cognitive-communication disorders and dysphagia, it is important to consider the impact of sensory impairment (hearing and vision), depression, current medications, and other factors (e.g., level of fatigue) on cognitive function. The Scope of Practice in Speech-Language Pathology (ASHA, 2016) includes hearing screening in the SLP’s scope of practice.
Hearing loss is a common result 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 et al., 2013). Therefore, it is important for clinicians to differentiate between hearing loss and cognitive impairment and to identify when one or both conditions are present.
Hearing screening of individuals with possible cognitive decline is essential to flag individuals with potential hearing loss and refer to audiologists for full hearing evaluations. SLPs play a valuable role in the design and implementation of effective screening programs and make appropriate referrals when necessary. See Scope of Practice in Speech-Language Pathology (ASHA, 2016) and ASHA’s Practice Portal page on Adult Hearing Screening. If participation in a valid hearing screening is not possible prior to cognitive screening due to lack of access or lack of ability to reliably participate, behaviors consistent with hearing loss and the potential impacts of unknown hearing status on testing results should be documented.
When completing cognitive screening for individuals with hearing loss, the clinician should ensure the individual is wearing any prescribed devices (e.g., hearing aids, cochlear implants, or osseointegrated hearing devices). Assistive listening technology should be used during screenings and assessments if the individual does not utilize prescribed hearing devices. See ASHA’s Practice Portal pages on Hearing Loss in Adults and Hearing Aids for Adults.
If visual deficits are suspected, the individual is referred for vision testing prior to completing cognitive-communication screening if possible. Prescription eyeglasses, as needed, are to be worn during screening. If prescription eyeglasses are not available, consider large print or using magnifying glasses. Adequate lighting is to be used in the test (and treatment) environment.
Depression is common in individuals with dementia and can adversely affect test performance. Cognitive changes associated with depression resemble the cognitive changes associated with dementia so closely 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.
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 pharmacology.
Comprehensive assessment includes an assessment of cognition, language, and communication. It may also include an assessment of swallowing and a complete audiologic assessment, as needed.
Consistent with the World Health Organization’s International Classification of Functioning, Disability and Health framework (ASHA, 2023; World Health Organization, 2001), comprehensive assessment is conducted to identify and describe
See ASHA’s Person-Centered Focus on Function: Dementia [PDF] for an example of assessment data consistent with the International Classification of Functioning, Disability and Health framework.
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., quarterly or annually) reevaluations are essential to adjust care plans to meet the changing needs of the individual.
The SLP determines the most appropriate assessment protocol based on the purpose of the assessment and the individual’s communication and swallowing needs and wishes. The information gathered during the assessment guides 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 & Bourgeois, 2018; Hickey, Cleary, Coulter, & Bourgeois, 2018; Hickey, Khayum, & Bourgeois, 2018; Lanzi et al., 2017). 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 or patient- or care partner–reported outcome measurements. These other data sources provide personally relevant information about the individual’s cognitive-communication strengths and needs in everyday situations, as well as their feeding and swallowing status. Conversations with the individual and their care partners can help identify the individual’s personal goals for continued, meaningful life participation. See ASHA’s resource on the general types of assessment tools, techniques, and data sources that can be used in SLP assessment.
A number of assessment tools have been standardized on individuals with dementia. They can be used to evaluate language comprehension and expression as well as the integrity of working, declarative, and procedural memory systems. Clinicians consider the severity and stage of dementia when selecting tests.
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.
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 the presentation of speech stimuli, providing reminders to respond, and allowing a “yes” response instead of raising a finger or pressing a button.
Objective tests, such as otoacoustic emissions (OAEs) or auditory brainstem responses (ABRs) may be used to assess hearing if subjective measures cannot be obtained due to the progression of dementia or other factors (Dawes et al., 2022).
Please see the Assessment section of ASHA’s Practice Portal page on Adult Dysphagia for general information about dysphagia assessment. Dysphagia assessment specific to individuals with dementia includes the evaluation of
When considering instrumental assessment for individuals with dementia, SLPs should also consider
Please see ASHA’s Practice Portal pages on Flexible Endoscopic Evaluation of Swallowing (FEES) and Videofluoroscopic Swallow Study (VFSS) for more information.
See ASHA’s Practice Portal page on Hearing Loss in Adults for information about the full audiologic assessment conducted by an audiologist.
The comprehensive assessment may result in
The Omnibus Budget Reconciliation Act (1987) mandates the 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; cognitive pattern/skills; and delirium. Although the law does not require that judgments about hearing and cognitive-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.
See the Treatment section of the Dementia Evidence Map for pertinent scientific evidence, expert opinion, and client/care partner perspective.
Dementia is a progressive disease, and goals 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 and safe and/or pleasurable eating at all stages of the disease process.
Dementia treatment may include compensatory or restorative treatment approaches that can target either improvement or maintenance of function. Given the progressive nature of the disease, treatment for dementia is often delivered as maintenance therapy, where services are designed to maintain a level of function or prevent further functional decline associated with the goals in the patient’s plan of care. Maintenance therapy may also be delivered by altering dosage of services into shorter episodes of care with periodic reassessment of needs as the disease progresses. Services that do not require the skills of the clinician and can be performed by a caregiver would not qualify as maintenance therapy. Payer coverage policies for maintenance services may vary.
Decisions about goals and treatment options are made in collaboration with the individual, family and care partners, and other health professionals. See ASHA’s resources on interprofessional education/interprofessional practice (IPE/IPP) and person- and family-centered care for further information. SLPs share information about dementia throughout the course of treatment with the individual and their family/care partners and provide family counseling and care partner 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 their wishes for continued care over time, including feeding and swallowing directives. See ASHA’s resource on person- and family-centered care for further information.
Consistent with the World Health Organization’s (2001) International Classification of Functioning, Disability and Health framework, person-centered intervention is designed to
Person-centered cognitive-communication goals can focus on
See ASHA’s Person-Centered Focus on Function: Dementia [PDF] for an example of goals consistent with the International Classification of Functioning, Disability and Health framework.
Audiology services (e.g., hearing aids, hearing assistive technology) may be indicated for individuals with hearing loss.
The clinician approaches clinical interactions with cultural humility and demonstrates sensitivity to social and cultural influences when sharing potential treatment recommendations and outcomes. 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. See ASHA’s Practice Portal page on Cultural Responsiveness.
Services should be provided in the language(s) used by the person with dementia, either by a multilingual audiologist/SLP or through the use of trained interpreters, when necessary. See ASHA’s Practice Portal page on Bilingual Service Delivery.
Views of the natural aging process and acceptance of disability vary by culture and may affect treatment decisions (Hinton et al., 1999; Low et al., 2009; Parker et al., 2010; Whitlatch & Feinberg, 2003; Williams & Harvey, 2013; Winslow & Flaskerud, 2009). For example, families may not seek help, or they may delay seeking help until symptoms are beyond early or mild stages (Hart et al., 1996; Pachana & Gallagher-Thompson, 2018; Regan, 2014). Families may fear the stigma of dementia, which can also affect decisions about seeking help (Benbow & Jolley, 2012).
See ASHA’s Practice Portal resource on Palliative and End-of-Life Care.
The clinician considers how feeding-related religious rituals and requirements can be observed and accommodated. Patients with dementia may have difficulty communicating and advocating for these needs, so the clinician can consult with religious leaders and care partners to determine ways to continue religious observances in a familiar and meaningful way while maintaining feeding and swallowing safety.
Dementia can have a significant impact on individuals in the LGBTQIA+ (lesbian, gay, bisexual, transgender, queer or questioning, intersex, asexual, and more) community. For example, transgender individuals with dementia may experience periods of confusion about medical issues related to their sex assigned at birth. Dementia may also make it challenging for LGBTQIA+ individuals to manage disclosure—they may lose some ability to determine with whom they share information related to their gender (Barrett et al., 2015), which can lead to confusion over how they discuss, share, and/or present their gender, and who is perceived as a safe person.
LGBTQIA+ 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). Due to historical experiences of discrimination and lack of access to safe care, there may be mistrust of and discomfort with health care professionals. Care facilities should be sensitive to the needs of older LGBTQIA+ patients and provide them with accommodations consistent with their identity (Voyzey, 2015).
See ASHA’s resource on supporting and working with transgender and gender-diverse people.
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 et al., 2015; Snyder et al., 2015). Changes in communication functioning due to cognitive decline and/or behavioral changes can have a significant impact on day-to-day interactions and can cause frustration. Audiologists and SLPs work with families and care partners 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 care partners 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 et al., 2007). Care partners benefit from being taught how to communicate using multimodal support and verbal and nonverbal strategies to reduce responsive behaviors. It is also important to teach care partners how to modify external strategies, communication supports, and the environment to support functional performance.
The goal of cognitive-communication treatment is to maximize the individual’s quality of life and communication success. This list is not exhaustive, and the inclusion of any specific treatment approach does not imply endorsement by ASHA.
Reality orientation is a therapeutic technique used to assist individuals in increasing their engagement with their surroundings through repeated reorientation to person, place, time, and situation. Compensatory treatment is typically used alongside verbal reinforcement and encouragement to engage with provided external aids. This can include, but is not limited to, the following:
As with most compensatory strategies, modifications may be needed to meet the individual needs of each patient throughout the disease continuum.
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 AT devices (e.g., memory aids and navigational tools) may have applications to dementia care (Bharucha et al., 2009). AT devices may be used to increase safety and independence, support activities of daily living, or decrease the likelihood of social isolation, among other potential uses (Pappadà et al., 2021). The selection of specific AT devices and systems depends on the stage of dementia, as individuals in the early stages of the disease are more likely to be able to use a wider range of devices and systems than individuals in the later stages (e.g., Collins, 2018). AT device selection is also highly dependent on the specific needs of the person with dementia and their care partner, with consideration of device costs and knowledge about and acceptance of these devices (Sriram et al., 2019).
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, but are not limited to, FM systems, external remote microphones, induction loops, and personal amplification devices. HATS may be appropriate for individuals with dementia who have hearing loss.
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. Individuals are actively engaged in optimal learning environments—typically, in a small-group setting (e.g., Aguirre et al., 2013; Woods et al., 2012). CST may also be used as a form of maintenance therapy (Lobbia et al., 2019; Orrell et al., 2014).
Environmental modifications are changes or adaptations to the environment to improve daily functions 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:
Assessing the individual’s performance in relevant settings (e.g., home, social setting, clinical setting) helps identify relevant environmental barriers and facilitators as well as potential modifications (Brush et al., 2011, 2012).
External 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 aids include changes to an individual’s communication environment (see the Environmental Modifications section of this Practice Portal page) and checklists, daily planners, calendars, programmable watches, pill reminders, and recorded messages (e.g., voicemails). Smartphones may be used to provide reminders of daily tasks, medication administration, and appointments.
These aids are more effective when they are specifically taught to an individual (Lanzi & Bourgeois, 2020). Personalization of the aids (e.g., preference, usability, modifications) promotes better generalization to everyday use (Lanzi et al., 2022; Sohlberg & Turkstra, 2011).
External aids such as memory books, memory wallets, scripts, 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).
The type and complexity of external aids or need for care partner support may need to be modified as a person progresses throughout the disease. For example, an individual with mild dementia may initially be able to use a smartphone to set reminders for medication administration but then may progress to using a shared digital calendar of reminders managed by their care partner before transitioning to more hands-on medication management assistance. It is important to design and start using aids as early as possible.
Reminiscence therapy uses external memory aids in the form of tangible prompts (e.g., photographs, familiar items, and music from the past) to stimulate conversations about past events, activities, and experiences. Reminiscence therapy is a client-centered approach that enables clinicians to create customized treatment plans that consider the personal and cultural aspects of each individual.
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 people with dementia in a supportive environment. It empowers individuals to engage in meaningful activities throughout the course of their lives (see, e.g., Bourgeois et al., 2015; Brush & Norris, 2017; Douglas, 2021; Douglas et al., 2018; 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 the environment. For example, 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 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. Simulated presence therapy 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 is a technique for learning and storing information so that it can be easily accessed. Spaced retrieval 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 et al., 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 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. Clinicians use validation therapy to communicate with individuals by acknowledging the feelings that underlie their behavioral and language deficits (Feil, 1982; Hitch, 1994; Mitchell, 1987; Neal & Wright, 2003).
Individuals progressing through the stages of dementia may experience increasing difficulties surrounding mealtime, including behavioral challenges (e.g., forgetting to eat, wandering), eating problems (e.g., difficulty using utensils or self-feeding), and swallowing disorders (e.g., dysphagia; Cipriani et al., 2016). 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 impact the health of an individual. Decisions regarding treatment should consider 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, Khayum, & Bourgeois, 2018).
Depending on the needs of the individual, goals may focus on one or more of the following:
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 interprofessional education/interprofessional practice (IPE/IPP).
SLPs are encouraged to alert and collaborate with relevant disciplines if they suspect that feeding and swallowing difficulties have impacted a patient’s nutritional status. Relevant disciplines include, but are not limited to, nutrition, nursing, and the attending physician.
Interventions may include the following:
For a comprehensive discussion of eating and swallowing interventions for individuals with dementia, see Hickey, Cleary, et al. (2018). See also ASHA’s Practice Portal page on Adult Dysphagia.
Tube feeding for supplemental or alternative intake is sometimes appropriate for individuals with dementia. The decision to implement tube feeding is complicated and should consider the potential complications of tube feeding and the individual’s quality of life. Decisions about tube feeding are made by a physician who should consider input from the team and reflect the wishes of the individual and their family.
Please see the Dementia section of ASHA’s resource on alternative nutrition and hydration in dysphagia care for further information.
The presence of dementia should not preclude fitting with hearing aids. 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 et al., 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 et al., 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 care partners on strategies to improve communication at home (e.g., improving listening environments) and provide ongoing counseling and support in the use of technology.
See also ASHA’s Practice Portal page on Hearing Aids For Adults.
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 typically palliative rather than rehabilitative. Palliative care can be provided alongside restorative medical treatment or end-of-life services and focuses on improving the patient’s quality of life by managing pain, discomfort, and emotional distress in chronic conditions. End-of-life care (also called “hospice”) is a type of palliative care that is not provided alongside restorative treatment. The expected outcome of intervention is not to improve abilities but to help the individual maintain dignity and quality of life.
Cognitive decline may make it difficult for the individual to make decisions about their care or to communicate their wishes for end-of-life issues. The ability to make such decisions may decline even early in dementia (Livingston et al., 2017). Individuals should consider planning for end-of-life issues as early as possible because of the degenerative nature of dementia. SLPs can educate individuals and their families/care partners on the expected course of decline in dementia and advocate for early decision making to empower the individual with dementia. If the individual’s communication skills are significantly impaired, SLPs may be able to help the individual communicate their preferences about how they would like to receive care and how they want to spend their time at the end of life.
Early on and throughout the course of 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). SLPs can incorporate visual aids into the medical end-of-life decision process to support the person with dementia’s understanding and reasoning (Chang & Bourgeois, 2020). It is also important to educate care partners on recognizing forms of nonverbal communication and providing them with examples of how to communicate nonverbally.
The wishes of the individual and their 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.
Please see ASHA’s Practice Portal resource page on Palliative and End-of-Life Care for further information.
See the Service Delivery section of the Dementia Evidence Map for pertinent scientific evidence, expert opinion, and client/care partner 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.
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. This can encourage the generalization of skills developed in treatment to community and home life.
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Content for ASHA’s Practice Portal is developed through a comprehensive process that includes multiple rounds of subject matter expert input and review. ASHA extends its gratitude to the following subject matter experts who were involved in the development of the Dementia page.
In addition, ASHA thanks the members of the Ad Hoc Committee on Dementia whose work was foundational to the development of this content. Members of the committee included Kathryn Bayles, Michelle Bourgeois, Tammy Hopper, Danielle Ripich (chair), Susan Rowe, and Amy Hasselkus (ex officio). Celia Hooper, ASHA vice president for professional practices in speech-language pathology (2003–2005), served as monitoring vice president.
The recommended citation for this Practice Portal page is:
American Speech-Language-Hearing Association. (n.d.). Dementia [Practice portal]. https://www.asha.org/Practice-Portal/Clinical-Topics/Dementia/