Communication Disability in the Dementias - Softcover

Softcover

ISBN 10: 1861565062 ISBN 13: 9781861565068

Publisher: Wiley, 2006

Synopsis

This book focuses on language and communication issues with older people with mental health problems. Radically revised and updated from the authors’ earlier book, “Communication Disability and the Psychiatry of Old Age”, this book recognizes that language and communication is not just the business of speech and language therapy but is relevant to all staff involved with people who have mental health difficulties. 

This book focuses on what older people with mental health difficulties require to maintain their independence and to minimize the effects of degenerative disease processes for as long as possible from a speech and language perspective.

• Relevant to all members of the multidisciplinary team involved within older people’s mental health services
• Each chapter is evidence-based and factual
• Reflects the substantial advances in the diagnosis and treatment of dementias

About this title

About the Author

Karen Bryan is a Professor of Clinical Practice at the European Institute of Health and Medical Sciences, University of Surrey, UK. Her current research interests include development of the Barnes Language Assessment, care sector training and education and practice development for the healthcare workforce.

Jane Maxim is Head of Department and Professor of Language Pathology at the Department of Human Communication Science at University College London.  She has a particular interest in language breakdown in different forms of dementia.

From the Back Cover

Communication Disability in the Dementias

Edited by Karen Bryan, European institute of Health and Medical Sciences, University of Surrey and Jane Maxim, Department of Human Communication Science, University College London.

Focusing on language and communication issues of older people with mental health problems, and based on the editors' earlier book, Communication Disability and Psychiatry of old Age, this book recognizes the many changes that have occurred in the last decade in relation to speech and language therapy practice. During this time there have been substantial advances in the diagnosis and treatment of dementias and a growing awareness of the need to treat older people appropriately. There is now recognition that speech and language are not just the business of the speech and language therapist but involves all t members of the multidisciplinary team who are dealing with those who have mental difficulties.

The book includes examples of evidence-based practice and is well referenced throughout. It discusses developing new services for older people and extending existing ones to help those with mental health problems maintain their independence and to help minimize the degenerative disease processes or as long as possible.

Edited by Karen Bryan, European institute of Health and Medical Sciences, University of Surrey and Jane Maxim, Department of Human Communication Science, University College London.

Focusing on language and communication issues of older people with mental health problems, and based on the editors' earlier book, Communication Disability and Psychiatry of old Age, this book recognizes the many changes that have occurred in the last decade in relation to speech and language therapy practice. During this time there have been substantial advances in the diagnosis and treatment of dementias and a growing awareness of the need to treat older people appropriately. There is now recognition that speech and language are not just the business of the speech and language therapist but involves all t members of the multidisciplinary team who are dealing with those who have mental difficulties.

The book includes examples of evidence-based practice and is well referenced throughout. It discusses developing new services for older people and extending existing ones to help those with mental health problems maintain their independence and to help minimize the degenerative disease processes or as long as possible.

Excerpt. © Reprinted by permission. All rights reserved.

Communication Disability in the Dementias

John Wiley & Sons

Copyright © 2006 Karen Bryan
All right reserved.
ISBN: 978-1-8615-6506-8

Chapter One

Health, ageing and the context Of care

Karen Bryan and Jane Maxim

Population issues

Across the EU, people over 65 form 17% of the population (ONS 2002a). The UK had a population of 59.2 million at the last census in 2001. For the first time, people over 60 form a larger part of the population (21%) than children under 16 (20%). There has also been a large increase in the number of people over 85: now 1.1 million, which is 2% of the population. In England and Wales there are 336 000 people aged 90 and over, and of these nearly 4000 are providing 50 or more hours of care to another family friend or carer.

Older people receive a large proportion of health and social care spending. In 2000, 28 billion were spent on hospital and community care with nearly two-fifths of this spend on people aged 56 and over (ONS 2001). In England and Wales, 5.2 million people provide informal care, including a million who provide more than 50 hours a week and 1.6 million who are in full-time work.

A major public health issue for the next century is the increase in the number of older people in the UK from ethnic minority groups (OPCS 1993). As of 2000, the largest ethnic group was Indian (984 000 people), then Caribbean and African descent (969 000) and Pakistani and Bangladeshi descent (932 000). Initiatives for these groups have tended to focus on physical health, and this together with the traditional stigma of mental illness in some ethnic groups has led to the relative neglect of older people from ethnic minorities (Rait et al. 1996). The term 'triple jeopardy' has been used to describe the challenges of racism, ageism and in some cases socio-economic deprivation faced by older people from ethnic minority backgrounds (Norman 1985).

Who are older people and where do they live?

Single-pensioner households make up 14.4% of all households, and more than two thirds of these have no access to a car. Many older people live alone: 52.5% of women and 25.7% of men aged 75-84, and 54.5% of women and 36.9% of men aged 85 and over.

The number of places in residential care for older people peaked at 247 000 in 1998, but fell to 237 000 in 2001 due to a levelling off of places available in the private sector and continued reduction in public sector places (ONS 2002b). Around 2 million children or children-in-law provide informal care to older adults living in another household and that figure has remained relatively stable between 1985 and 1995, although there has been a shift from children as the most likely carers to spouses. However there has been a 25% decline in intergenerational care within the same home. This is thought to be associated with trends such as more women working outside the home and the previous rise in institutional care (Pickard 2002).

Attitudes to older people and their health

Greengross et al. (1997) described ageing as a subject that should be top of world agendas. There are more older people living longer with increasingly fewer resources to care for them. Shifts in government policy in developed countries have encouraged preservation of independence. Emphasis is being placed upon providing support to enable people to live with age-related degenerative conditions such as dementia (Benbow and Reynolds 2000). Care of older people is a recognized specialism within medicine and other health professions. Another positive development is that age discrimination is considered a negative factor to be avoided and age is not now a valid criterion to restrict access to services (National Service Framework for Older People, DH 2001). Much has been written about the benefits of preventive care and the need to manage degenerative difficulties rather than accept them as an inevitable consequence of older age. For example, the effects of reduced hearing on communication and psychosocial functioning are recognized (Heine and Browning 2002) and studies have shown that intensive support for older people with hearing difficulty produces significant improvements in social functioning (Sherbourne et al. 2002).

The boundary between cognitive changes associated with normal ageing and those associated with dementia is accepted as unclear (Figure 1.1). The Nun study showed that education may function as a buffer to protect against the effects of dementia on ageing (Snowdon et al. 1996). However, the study also showed that pathological changes associated with Alzheimer's disease are present in the brains of those older sisters who do not show dementia, suggesting that other factors such as environment and lifestyle may mediate in pathological processes (Stern et al. 1994). These findings are helpful in encouraging professionals to take positive attitudes towards the support and care of older people with dementia. In Chapter 3 we look at the contribution of general practice and in Chapter 9 at measures to support carers; Chapter 7 examines whole-system approaches to dementia.

Overview of language and ageing

Age-related reduction in cognitive functioning (including language) has received much attention in recent years (see Nussbaum et al. 1996 for a review of ageing and communication). The traditional view of decline in functioning across the board has long since been shown to be an inaccurate and simplistic view. Losses and gains are now considered, with age-related decline often a function of the exact task. For instance, recognition of pictures and completion of word stems have been convincingly shown to be age-invariant memory tasks (Park 2000). Salthouse (1991) described four mechanisms hypothesized to account for age-related differences in cognitive functioning:

speed at which information is processed

working memory function

inhibitory function (affecting the ability to focus by inhibiting unwanted information)

sensory function.

These factors need to be distinguished from actual changes in language functioning. The effects of health problems such as cardiac or peripheral vascular disease on cognitive functioning also need to be distinguished from normal ageing (Elwood et al. 2002).

A further important factor is individual variation. Parameters such as education, experience and cognitive style will influence the effects of ageing. Christensen (2001) reported, from an extensive longitudinal study of older people in Australia, that education, good health, genetic factors (such as absence of the APOE epsilon4 allele) and activity were protective of cognitive decline, and that diversity in cognitive ageing suggests that more than one process may be operating to produce cognitive decline. Butler et al. (2004) reviewed the evidence for cognitive decline in normal ageing and concluded that social engagement, intellectual stimulation and physical activity play a key role in maintaining cognitive health and preventing cognitive decline. Factors such as circadian rhythms may also influence processing. Yoon (1997) found that older people's preference for reading the paper and shopping first thing in the morning related to their tendency to be more energetic and mentally alert in the morning.

Age-related changes in cognitive functioning may also result in developmental 'gains' (Dixon 2000):

Gains despite or independent of constraints provided by losses, e.g. logical, abstract thinking (Sinnott 1996) and the concept of 'wisdom' (Baltes and Staudinger 1993) are thought to emerge post young adulthood.

Gains as losses of a lesser magnitude, i.e. that some consolation may be taken from cognitive losses that emerge later than expected, at a level less than feared or predicted or at a level that does not impair everyday skills. For example, the Seattle study suggested that 90% of older people in four age groups maintain at least two intellectual abilities (Schaie 1996).

Gains as a function of losses, i.e. occasioned by losses or that compensate for losses, for example, collaborative experiences during assisted performance (Dixon and Gould 1998).

Attention is a complex area, with no evidence for older people having an automatic decline and assessment findings very much reflecting exact task demands. There is some evidence that older people have difficulty in directing attention, but the exact effects of ageing versus pathology on attention remain uncertain (Perry and Hodges 1999).

Memory is also a complex area of cognition, with considerable interaction between variables such as task demands, familiarity and mode of response (see Stevens et al. 1999). Craik (2000) summarizes what professionals dealing with older people should be aware of in terms of memory functioning, particularly during assessment. It should be expected that older people might be less accurate in recalling recent events, especially if these involve specific details of time and place. Telephone conversations or interviews should avoid complex instructions or questions. Priming effects may have more influence for older people, e.g. providing examples may bias older respondents' choice of answers. Reduced perceptual clarity (visual or auditory) may reduce immediate memory for initial alternatives in a multiple-choice format. The decline in working memory capacity may also bias answers to the most recently presented alternative. Repetition of information may result in that information being viewed more favourably.

Older people may also have sensory losses that affect communication functioning. Age-related decline in hearing (presbycusis) is very common, with 2.5 million people in the UK over the age of 70 thought to have hearing impairment that would benefit from an aid (Hanratty and Lawlor 2000). See Chisholm et al. 2003 for a review of age-related deafness. There are also age-related changes in relation to speech perception. Wingfield (2000) highlighted four important principles relating to adult ageing and spoken language comprehension. The extent to which these broad principles are important to any older individual will depend on their individual profile:

Older people will use top-down information drawn from linguistic context to supplement an impoverished bottom-up signal (as do younger people under difficult listening conditions). Provision of contextual information will therefore assist comprehension.

Older people have difficulty in processing speech structures that place a burden on working memory. Therefore long sentences, sentences whose comprehension requires memory for referents that occurred far previously in the passage and sentences with high prepositional density or complex syntax should be avoided.

Normal prosody (intonation, timing and stress) assists older listeners by aiding the rapid detection of the linguistic structure and the semantic focus of an utterance. Exaggerated prosody (often associated with 'elderspeak') should be avoided (Brown and Draper 2003).

Pausing at natural processing units (such as sentences and clauses) allows additional time for speech processing and increases comprehension relative to rapid speech.

Age invariance (preservation of a skill despite ageing) has been demonstrated for many aspects of language comprehension and production (Kemper and O'Hanlon 2000). Where age-related changes occur, for example in the comprehension of complex syntax, these reductions are hypothesized to reflect working memory constraints. More recent studies suggest that immediate syntactic processing is age-invariant, although post-interpretive processes required for text integration and discourse comprehension may be vulnerable to age-related working memory reduction (Kemtes and Kemper 1997). Older people tend to adopt strategies of parsing text into smaller units and utilizing background information, resulting in few difficulties in processing narrative prose (Radvansky and Curiel 1998).

For language production, ageing is associated with sensory changes such as dry mouth and muscular changes that result in slowing of motor production. These changes should be regarded as contributing to reductions in efficiency rather than deficits (Xue et al. 2001). Changes in dentition, particularly ill fitting dentures and absent teeth or dentures, can also affect speech production (Roessler 2003).

It is important to exclude other possible reasons for a cognitive impairment before assuming a deficit or a reduction in functioning. For example, older people tend to take more medication than younger people, and are more prone to medication side effects (Swift 2003). Drugs which work on the central nervous system, such as some analgesics and sleeping medications, may depress cognitive functioning and may affect testing.

However, recent research has also shown that older people's daily capabilities often appear not to reflect the age-related 'decline' discussed above (Park and Gutchess 2000). There is considerable evidence that older people function well in most aspects of daily life and work. Two aspects of the ageing cognitive system appear to facilitate functioning:

Knowledge is maintained across the lifespan and may even increase (Echt et al. 1998), providing an extensive knowledge base for problem-solving and addressing the needs of everyday life.

Frequent and familiar behaviours become automatized and therefore require little cognitive recourses to perform (Jacoby et al. 1996).

Thus older people can successfully cope with the cognitive demands of complex medication regimes. Park et al. (1999) showed that older people made fewer errors than middle aged people in taking medication for rheumatoid arthritis. Literature is also emerging on positive advantages to older people of working (Park 1994), and on their ability to perform at a high level particularly where they are expert or in a familiar environment and where they continue to train and update their skills (Salthouse et al. 1996).

Recent approaches to older people with dementia

Drug therapies have demonstrated benefits for people with Alzheimer's disease. Studies have assessed benefits of drug therapies in terms of cognitive function, global severity, behaviour, activities of daily living and burden of care. At present the benefits of various drugs are being researched (Birks and Harvey 2003, Areosa Sastre et al. 2004, Loy and Schneider 2004). The NICE appraisal consultation document on donepezil, rivastigmine, galantamine and memantine suggests that the effects are limited and do not assist all patients (NICE 2005). However, there is now renewed interest in demonstrating the benefits of behavioural and psychological interventions (see Clare and Woods 2001 for a review of cognitive rehabilitation).

The concept of treatment has though challenged traditional assumptions that people with dementia cannot be treated. Rehabilitation for older people has been firmly enshrined in the NHS Plan for older people (DH 2000) and researchers are beginning to recognize the relevance of cognitive rehabilitation for people with dementia (Camp and Mattern 1999). Clare and Woods (2001) state that:

defining rehabilitation as a process of active change aimed at enabling people who are disabled by injury or disease to achieve an optimal level of physical, psychological and social function implies a focus on maximizing functioning across a whole range of areas including physical health, psychological well-being, living skills, and social relationships. Such an approach is just as important for people with dementia and other progressive disorders as it is for people with non-progressive acquired brain injury. (pp. 193-194)

Bayles and Esther (2003) also advocate the value of behavioural interventions to enhance communicative functioning for people with dementia. Alternatives to the medical model of dementia, for example Kitwood's dialectal model (Kitwood 1997; see Chapters 7 and 8 for more information on Kitwood's approach) and Sabat's social constructionist model (Sabat 1994), give a theoretical basis for an approach to dementia that addresses the needs of people with dementia and their carers, taking into account the influence of biology, individual psychology, and social environment. Hagberg (1997) suggests that intervention should aim to enhance coping skills and self-efficacy, combat threats to self esteem and help the person with dementia to make the best possible use of their individual resources. The evidence base for interventions aimed at enhancing language and communication is beginning to emerge.

(Continues...)

Excerpted from Communication Disability in the Dementias Copyright © 2006 by Karen Bryan. Excerpted by permission.
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Edition details

• Publisher: Wiley
• Publication date: 2006
• Language: English
• ISBN 10: 1861565062
• ISBN 13: 9781861565068
• Binding: Paperback
• Edition number: 1
• Number of pages: 354
• Editor: Bryan Karen