The cognitive changes that occur in individuals with dementia are not clearly and completely understood, but their effects on language and the ability of the person to communicate and to interact appropriately with others in their environment are profound. Dawson et al state that individuals with Alzheimer's disease are at risk for social isolation because of language decompensation and other cognitive loss.2 In a 1982 study,3 communication difficulties were cited as the sixth most common problem faced by family members caring for demented individuals. The other more frequently named problems were memory disturbances, catastrophic reactions, demanding and critical behavior, night waking, and hiding things. AU of these either affect communication or are negatively influenced by a diminished ability to communicate.
Williams states that effective communication, both verbal and nonverbal, is a key component in effectively caring for mese individuals.4 Furthermore, the breakdown in communication caused by the disease can be irritating and overwhelming for both patient and nurse. Families often describe the frustration and hurt of living with a person who no longer remembers them and their past together. The fluctuation in the character of their speech and communication can be particularly difficult (Newsweek. Dec 3, 1984:56-62).
Impaired communication, in addition to many problematic behaviors, makes working with or caring for someone who is demented a challenge and can easily lead to frustration, anger, or a desire to ignore the individual. General strategies for managing the problematic behavior of demented persons, such as gaining eye contact, minimizing distractions, and giving one-step instructions, are distributed fairly widely in the gerontological and nursing literature. Less widely distributed are the results of research looking at the explicit changes that occur in the language of Alzheimer's disease victims.
REVIEW OF LITERATURE
Alzheimer, in the original description of the disease that came to bear his name, emphasized that his patient was aphasie in addition to having impaired memory, paranoia, and normal motor function.5 He noted paraphasia, alexia, and agraphia. Since then, attention to language deficits as a criteria for dementia of the Alzheimer's type (DAT) has varied. In the current American Psychiatric Association Diagnostic and Statistical Manual,6 communicative disorders are listed as a possible but not essential component of dementia. These criteria aie for establishing the broad category of dementia and are not specific for a diagnosis of DAT.
In the past few decades, research in dementia has increased tremendously. Only recently, however, has there been significant research interest in the changes that occur in .language and communication. There is an increasing body of knowledge in this area and growing evidence that identification of sensitive, consistent, and specific alterations in verbal output may provide an additional criterion for distinguishing DAT from other causes of cognitive impairment.712 Emery contends that linguistic cues are among the first to appear in the progressive degeneration of higher order cortical processes in Alzheimer's disease, and that the pattern of linguistic deterioration follows an orderly predictable progression in the reversal of language development.13
This article will discuss the research in language changes in DAT as background to understand changes exhibited by patients and to guide interventions. Some specific research will be cited, but the emphasis will be on the conclusions drawn by the researchers.
Many of the words used in discussing communicative disorders are common in everyday usage and, for clarity, need to be defined in this context. Speech refers to the motor production of sounds rather than an acoustic representation of language. Language is a symbol system by which sound is paired with meaning. Linguistic communication is the cognitive process of sharing ideas through language. It is important to note that communication is broader than linguistic communication, and in dementing illness, the ability to communicate (intentionally) is impaired. This impairment affects both linguistic and nonlinguistic modes. It is also important to stress that the ability to communicate is affected more than either speech or language (Figure).
Language has a number of linguistic features that have been theoretically separated to better understand the processes of language and communication. This is essential for research and the generation of knowledge, and these theoretical subsystems will help to organize the research findings. It is important to remember, however, that there is considerable interaction between these subsystems, and in practice it is difficult to isolate them from each other clearly. The subsystems of linguistic knowledge that will be broadly discussed are phonologic, syntactic, semantic, and pragmatic knowledge.
Phonologic knowledge is the knowledge of the correct use of sounds of language and the rules that govern their occurrence. It includes knowing the general rules about such things as stressing or emphasizing syllables within words. This is information we grow up with in speaking and using language and, as a rule, it is not in our conscious awareness. In demented patients in the early and middle stages of the disease, these rules are wellmaintained and many patients with severe disorders are able to recognize and correct phonological error even when they are unable to comprehend utterance meaning and use.7,14
Syntactic knowledge is the knowledge of rules that govern the way words are put together in sentences. This knowledge allows the recognition of structural ambiguities and the relationship between sentence elements. These are the things reflected in grammar usage and, as with phonology, there is little deterioration in early and moderate dementia. In a study of demented subjects by Kempler, Curtiss, and Jackson, analysis of both spontaneous speech and a written task revealed a normal range and frequency of syntactic constructions.15 The use of syntactic cues was demonstrated to be significantly more intact than the use of semantic cues. Later in the disease process, there may be poor comprehension of grammatically complex structures.
GLOSSARY OF TERMS
A partial explanation of the preservation of syntax and phonology in DAT has to do with the notion of automaticity. These processes largely operate independently of the subject's conscious control. They are learned early in life and are often repeated. Bay les writes, "the less dependent the rules of the system on conscious awareness for their application, the less vulnerable the system to the effects of dementia."16 Therefore, patients with significant dementia may still be able to count, say the days of the week, and correct errors in grammar when they are having considerable difficulty using language to communicate ideas.
The other two types of knowledge, semantic and pragmatic knowledge, are more vulnerable to the effects of DAT. These processes are more complex and necessarily dependent on memory, conscious processing, and the results of other mental systems and are closely intertwined. Semantic knowledge is a complex concept that includes understanding the meaning of words and sentences and their reference; it enables us to recognize a string of words as meaningful and groups of words that are synonymous or antonymous. The ability to name is considered a semantic function. To have intact semantic knowledge is to be able to derive the sense and reference of the expressed language.
Pragmatic knowledge refers to the individual's knowledge of how language is used and includes the ability to recognize the intentions, purposes, and beliefs of speakers in producing particular utterances. It deals with sensitivity to variables such as who is being addressed, the time available, the information shared by the conversants, and attention to issues such as taking turns in conversation.
In DAT, word finding is one of the early complaints, particularly in generative naming ability. There is progressive decline in both receptive and expressive vocabulary. Verbal expression is often rambling and vague. Reduced receptive vocabulary, impaired word fluency, and difficulty in providing concise definitions, as well as difficulty in confrontational naming, were identified as changes in the language of dementia subjects. 17 Additional difficulties have been shown to be circumlotions and confabulation, semantic paraphasias, use of empty words, use of vague generic words in place of words with more precise meaning.18,19 Individuals with DAT also have difficulty picking up on subtleties such as sarcasm, analogies, and nonliteral or ambiguous statements.
Analysis of speech samples obtained through open-ended questions about common topics found that the DAT subjects used more than twice as many words and more than four times as many turns as the control group to relate information about the topic.20 In a study by Murdoch and Chenery, six categories (verbal expression, repetition, auditory comprehension, reading, writing, and articulation) of speech/language function were examined. 10 The DAT patients scored significantly lower than the controls in five of the six categories. There was no significant difference in the articulation abilities of the two groups.
In the latter stages of the disease, more profound lexical disturbances may be manifested as jargon, extremely laconic speech, or even mutism.18 There is often marked anomia, grossly reduced vocabulary, increased impairment of comprehension, and increased use of neologism, Paraphasie errors, and jargon.21
IMPLICATIONS FOR NURSING PRACTICE
Does the research on language changes and DAT have implications for nursing practice? In summarizing the findings of the research discussed in this article, it is clear that there is variation in the effects of DAT on specific subsystems of language in the different stages of the disease. This is one of the reasons, particularly early in the disease process, that it is difficult to evaluate the individual's competence or his abilities to understand and communicate. Individuals may respond to many routine tasks appropriately, be aware of their surroundings, and correct grammar errors but have significant difficulty reasoning and communicating ideas.
It is also important to remember that early in the disease, individuals are often aware of elements of deficits in their communication and attempt to cover this up using a variety of devices such as confabulation, indignation, anxiety, and admission of difficulty coping with a particular task or problem.19 Another common response is to withdraw and avoid participation to decrease chances of having to deal with a troublesome situation or demonstrate their deficit.
These factors clearly point to the need for a more detailed cognitive assessment beyond the usual practice of checking alertness and orientation. FoIstein's Mini-Mental Status Exam (MMSE) is quick and easily administered and is helpful in identifying general cognitive deficits.22 Cummings et al found a consistent relationship between increasing impairment of language function and increasing severity of dementia, as reflected in decreasing MMSE scores.8
The findings also have implications for our communication with individuals with dementia and for teaching family members and significant others who provide the majority of care and supervision that these individuals require. Because it is not possible to alter the communication pattern of the dementia victim, those who engage him need to take the initiative. By controlling some of the language variables, such as rate of speech, amount of new information, topic, word choice, and effective use of nonlinguistic communication, the nurse or family member can improve the chances of successful interactions. The following behavioral and communication techniques will be helpful in guiding the development of plans of care for individual patients.23,24
Behavioral and Communication Techniques for Individuals with Dementia
Modify question asking. As dementia progresses, the ability to generate ideas and think of possibilities diminishes, so avoid open-ended questions. Ask questions that include limited choices: Would you like to go for a ride or take a walk?
Help minimize the effect of poor memory. Use short simple questions. Minimize the use of pronouns; repeat the name of the person each time instead. When giving instructions, break down tasks into simple steps and give one step at a time.
Be redundant. Repeat yourself and restate critical facts several times in relaying a message.
Use right-branching rather than leftbranching sentences. Left-branching sentences ("Because Ben left the house without his coat, his mother was upset") are more difficult to process and require more memory than rightbranching sentences ('His mother was upset because Ben left the house without his cou/").25 Keep sentences short and simple.
Modify the topic. Because these individuals have difficulty generating ideas, conversations about complex and abstract subjects will be difficult for them to follow and participate in. Keep topics focused on situations with which the person is familiar or that are directly observable.
Be direct. Be explicit about what you want them to understand. Dementia victims have difficulty processing implied information. Instead of saying "Do I look like I have nothing to do?" say "I am too busy to talk now." Performance errors may occur because the person may not remember the purpose, task, or instruction, not because of inability to do the task.
Avoid using analogies. Seeing relationships between objects or events is precisely the difficulty that these patients have; therefore, analogies will be confusing.
Restate and paraphrase what is not understood. The cognitive deficits that the person develops occur gradually and with variability. Use different words to express your ideas and keep it simple. Remember that at some point, logical explanations will cease to have meaning and persistence in explaining leads only to frustration.
Be literal. Nonliteral terms are used frequently in conversation: "That dress is a knockout"; "This dessert is heavenly." Demented persons have progressive difficulty inferring the meaning of nonliteral terms.
Provide illustrations. Drawings and photographs give additional cues and make it easier for demented persons to grasp meaning.
Establish eye contact before addressing the person. Securing eye contact helps to get the individual's attention and helps him focus on you and what you are saying. Your facial expressions help communicate your intention.
Enhance what you say with frequent gestures. Additional physical cues and emphasis increases your chances of successful communication.
Avoid environmental distractions. Attention to the environment will increase the possibilities of success. Noisy and busy surroundings will distract the demented person. It will be easier to get and keep their attention in a quiet environment.
Do not agree to things you do not understand. Do not pretend to understand vague or rambling speech. If the verbalizations do not make sense to you, search for important clue words and repeat a portion of the jargon to evoke a feeling of being connected with the person.
Give the person time to respond. If a verbal or nonverbal response does not occur in 1 to 2 minutes, repeat the exact set of verbalizations and gestures.
Be patient. If you or the patient become frustrated, take a break and try again later. Remember that fatigue, stress, and trying to hurry have negative effects. Although they are not able to comprehend the reasons, demented persons still seem to sense emotions such as frustration and anger. This may lead to an escalation of their disruptive behavior. The opposite is also often true. A quiet, soothing voice, gentle touch, or a calm presence may reassure an individual who is agitated.
Caring for individuals who are demented is a challenging, often exhausting task for caregivers, whether family or professional. Being able to connect and communicate with the individual is an essential and humanizing aspect of the care and interaction that occur. Knowledge of the language and communication deficits provides a basis for setting realistic expectations and planning interventions, and thereby improves the opportunities for continuing successful communication as the disease progresses.
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