Alzheimer's disease (AD) is a progressive deteriorating neurogenerative disease. It is characterized by memory loss, speech and language deterioration, impaired visuospatial skills, behavior and personality changes, and a decline in thinking ability.
Alzheimer's disease is the most common cause of dementia among people age 65 and older. It represents an enormous health problem in the United States. The affect on individuals, families, the health care system, and society as a whole is monumental. Scientists estimate as many as 4 million people currently have the disease and this prevalence doubles every 5 years beyond age 65. It is also estimated that approximately 360,000 new cases will occur each year, and this number will increase as the population ages (Brookmeyer, Gray, & Kawas, 1998).
Since the turn of the century, life expectancies have increased dramatically. More than 34 million people, 13% of the total U.S. population, are now age 65 and older. According to the U.S. Bureau of Census, this percentage will accelerate rapidly beginning in 2011 when the first baby boomers reach age 65, and will represent 18% of the total population by the year 2025. The 85-and-older age group is one of the fastest growing segments of the population. The U.S. Bureau of Census estimates that this group will number nearly 8.5 million by the year 2030 (National Institute on Aging, 1999).
The emotional and physical efforts related to the demands of AD on the patient, family caregivers, and friends present enormous economic and psychological challenges. This article focuses on the numerous problems associated with cognitive-linguistic decline in AD.
Language and Discourse
The nature of the communicative decline that occurs during the course of AD has been well-documented Bayles Sc Kaszniak, 1987; Ulatowska & Chapman, 1991). Table 1 summarizes the effects of the disease on language during the stages of disease progression. Decline in various aspects of language function is observed early and increases as the disease progresses.
Discourse studies in populations with AD have been widely reported in the literature (Chapman, Ulatowska, King, Johnson, & Mclntire, 1995; Chenery & Canter, 1992; Mentis, et al., 1995;Ripich&TerreIl, 1988; Tomoeda & Bayles, 1993; Ulatowska, et al., 1988). The study of discourse is essential because it is an aspect of language that contributes significantly to the communication breakdown observed in patients with AD (Mentis et al, 1995).
Discourse is the ability to produce meaningful messages. It has been defined as a sequence of connected sentences in monologue, dialogue, and text (Kintsch Sc van Dijk, 1978). The most common form of discourse production is spontaneous conversation, which depends on several requirements (e.g., each speaker has a chance to talk, only one speaker talks at a time, brief gaps between turns) resulting in a system of turn-taking (Terrell & Ripich, 1989).
Another common form of discourse production is narrative discourse. Narrative discourse refers to a linguistic representation of an event or series of events. Storytelling and relating past events are examples of narrative tasks commonly performed by speakers, and thus provide further insight into levels of discourse competence (Terrell & Ripich, 1989). Discourse competence may include other communicative abilities such as paralinguistic behavior and nonlinguistic behavior. Paralinguistic abilities refer to the prosodie, intonational, and suprasegmental features of language (e.g., pitch, rate, stress, intensity). Nonlinguistic abilities refer to contextual information conveyed via physical proximity, movement, gesture, eyegaze, or facial expression.
The problems with discourse in AD that have been most widely reported include (Appell, Kertesz, & Fisman, 1982; Mentis et al., 1995; Ripich & Terrell, 1988):
PATTERNS OF COMMUNICATION CHANCES ASSOCIATED WITH AD
* Descriptions of confusing, vague, and empty speech.
* Verbosity and unnecessary repetition of ideas.
* Disruption of cohesion or connectiveness of discourse and lack of coherence (how well the statements and sequence of sentences are related).
* Problems in turn-taking and speech.
* Reduced or disordered information content and thematic structure in comparison to the speech of healthy elderly individuals.
Patients with AD tend to take shorter turns and a greater number of them, use more requestive speech acts (e.g., directives) and indefinite references, use fewer assertives, initiate more new topics (often inappropriately), and have poorer topic maintenance skills than healthy older adults. Conversational turn-taking and the ability to produce socially ritualized aspects of conversation (e.g., greetings) are maintained (Ripich, Vertes, Whitehouse, Fulton, Ekelman, 1991).
Reminiscing: Pilot Observations
Reminiscing is a type of discourse that recalls a "long forgotten" experience (Webster & Young, 1988). Reminiscence therapy, a nursing intervention, has been used in acute and long-term care settings for more than 20 years. There are types of reminiscence that clearly serve to enhance the self-worth of older persons who are recalling their past accomplishments, experiences, and exploits. Numerous gerontological articles have addressed the nature, role, frequency, and particularly the effects of reminiscence in late life (Sherman, 1991).
Butler's life review program (1963) uses reminiscing with the goal of assisting the aging patient to achieve integrity. Butler's Guided Life-Review Program is designed to assist patients in working through their unresolved issues. Guided Life-Review sessions are conducted by a leader, trained and experienced in professional clinical skills, who assists clients in working through their life-long resentments and in coming to terms with their disappointments. This type of group should not be confused with reminiscence for the purpose of enjoyment. The application of reminiscence in this pilot study refers to recreational reminiscence only. Emphasis is placed on remembering life experiences for the simple pleasure of re-experiencing happy or satisfying occasions, and sharing heartfelt experiences with others.
Reminiscence is an enriching and complex experience having many purposes and functions when used with patients with AD. There have been no studies cited in the literature to date that examine the effects of reminiscence activities on discourse interactions in patients with AD. The National Institutes of Health (NIH) AD research program conducted informal observations of conversations among patients and staff including a certified recreation specialist (CTRS), a registered nurse certified in gerontological nursing (RNC), and a certified speech-language pathologist (SLP). Researchers noted that when patients with AD discussed heartfelt, memorable events, their language appeared more fluent.
Although still not necessarily within normal limits, discourse appeared more cohesive than when the same patients were conversing in more structured environments, such as during testing sessions. The sequencing and expression of ideas and sentence structure were often more complete during these activities. Patients maintained appropriate topics of conversation and used appropriate social exchanges depending on the form of discourse.
Based on informal observations, it was hypothesized that objective ratings of conversational discourse would be better (less impaired) in patients with AD when obtained during less structured environments, such as during the reminiscence group (RG) activity as compared to ratings obtained within conversational environments with more structure, such as diagnostic language (DL) session. The purpose of this article is to report the preliminary findings of a pilot study in which conversational and narrative discourse skills observed in different testing environments in patients with AD were compared.
There were 15 participants in this pilot study, 6 women and 9 men. The participants' ages ranged from 54 to 81 years, with a mean of 68 years. Their educational levels ranged from 8 years to 22 years, with a mean of 15 years of formal education. The Mattis Dementia Rating Scale (Mattis, 1988) was administered in order to establish a rating of dementia severity. The participants' scores on this battery ranged from 89 to 136 (of a possible 144), with a mean score of 114. These investigators consider scores of 140 to 144 within normal limits. Therefore, the participants ranged in severity from mild to moderate. All participants were right handed, with the exception of one, and they represented diverse geographical and ethnic backgrounds. Table 2 provides a profile of study participants.
All participants were being evaluated for probable AD in the patient clinical research nursing unit serving the Geriatric Psychiatry Branch of the National Institute of Mental Health. Participants presented with no other neurological or psychiatric disorders, based on current medical records. Visual and hearing acuity (with aids) were within normal limits. Informed consent was obtained for all participants as part of the overall clinicalresearch evaluation.
PROFILE OF STUDY PARTICIPANTS
The single RG session described in this study was facilitated by a CTRS, a RNC, and a SLP. The number and expertise represented by the group facilitators was typical for this setting. Emphasis was placed on remembering life experiences that enable the patient to relive satisfying memories and share information with the group. Reminiscence can be entertaining, especially when the recalled event is lively and vivid. When this happens, it is also clear that the shared experience lifts the spirits of the listeners as well as the storyteller.
Objective ratings of conversational and narrative discourse skills were obtained during a less structured RG session and during a more structured DL session. Comparisons of performance were made between the two sampling conditions. Measures were obtained for the following aspects of discourse and communication:
The NIH Rating Scale for Functional Communication Abilities of Dementia (Moss, 1993) is presented in the Appendix.
The duration of the conversational sample being rated was held constant (i.e., 20 to 30 minutes) across the two sessions. Topics selected for discourse assessment in the DL session and the RG session were generally similar (i.e., relating to some remote memory event of the patient). There were always two or three conversational participants in the DL session, and three to five conversational participants in the RG session. Approximately half of the participants received initial ratings during the DL session, and half of the participants received initial ratings during the RG session. The ratings were not conducted under blinded conditions.
Reminiscence Group. The less structured (60- to 90-minute) RG sessions were held in a "living room" environment. This area provided a level of familiarity to the patients. A certified SLP, who also participated conversationally in the session, evaluated a single patient during each RG session. Programs from Bi-Fokal Production, Inc. (Madison, WI), multi-media "remembering kits," were used to stimulate conversation during RG activities. Each program within the kit contained a program manual with illustrations and discussion starters including skits, jokes, picture sets, a variety of props, and media presentation materials (e.g., cassette tape, video, slides). All of the multi-sensory program materials were subject-specific, dealing with familiar topics such as pets, holidays, county fairs, die depression era, school days, or work life.
Group members read a humorous skit at the beginning of the session. This type of introduction served to set the tone of each RG. Usually a slide presentation followed, providing further elaboration of the theme. Props appropriate to the subject (i.e., an engineer's hat in the train kit) were also used in order to enhance conversation. Audiotapes were occasionally used to accompany "sing-along" portions of the program. Although a general format was available through these materials, one was not strictly adhered to, thus allowing less structure. Patients were encouraged to discuss their memories whenever they thought of something that they wanted to share. A story that was recalled by one patient often prompted a second patient's recall and subsequent storytelling.
FREQUENCY OF OBSERVED CHANGES IN DISCOURSE RATINGS
Diagnostic Language Session. In contrast to the RG session, the DL session was conducted in a clinic-testing suite. The room was well-lit and free of excessive visual and auditory distracters. A certified SLP or a graduate intern conducted all evaluations. Sessions lasted no more than 90 minutes. In most cases, the SLP had had earlier contact with the patient. If the patient had not developed a rapport with the clinician, time was taken prior to administering the assessment to do so. The purpose of this segment of the session was to (re)establish rapport and a pattern of conversational exchange with the parient. A variety of open-ended topics were used at random to elicit conversation. For example, patients were given opportunities to describe topics such as favorite hobbies, activities with families and friends, travel experiences, and occupational history.
A comprehensive evaluation of cognitive-linguistic deficits associated with AD was conducted using the Arizona Battery for Communication Disorders of Dementia (Bayles & Kaszniak, 1987). For the purpose of this study, only tasks within the Episodic Memory, Linguistic Expression, and Linguistic Comprehension subtests were administered.
Discourse interactions were assessed using the NIH Rating Scale for Functional Communication Abilities of Dementia. Procedures for assessing narrative and spontaneous conversational discourse interactions were as follows: The clinician requested that the patients tell a story or relate a past event (e.g., "Tell me about your last vacation"). The SLP used appropriate verbal and nonverbal prompts, such as eum-hum" and head nods during the interaction; asked open-ended questions, and avoided using a "question and answer" format.
The SLP engaged in interactive conversation with the patient in order to assess spontaneous conversational discourse abilities. The SLP generally initiated this segment by establishing a topic of probable interest to the patient.
Assessment of other discourse elements (i.e., linguistic and paralinguistic) did not require specific administration procedures. These ratings were made after completion of the spontaneous and narrative discourse segments and reflected the patients' performance in each of the observational contexts. Scoring of discourse interactions was completed during the session. The clinician placed a check mark beside each of the features observed. Ratings were assigned immediately following the session. An overall discourse interaction score was obtained for each context and used later to compare performance in the two discourse settings.
The data selected for analysis were the frequency of three outcomes in ratings from the RG and DL sessions. In the absence of systematic differences between the two discourse settings, chance variation in the conversational discourse of an AD patient might yield better ratings in the RG session, better ratings in the DL session, or the same ratings in both sessions. These three outcomes could be expected to be equally likely. Therefore, for each of the four discourse categories, each patient's ratings were classified as either "same" (unchanged in the two settings), "better" (less impaired in the RG setting compared with the DL setting), or "worse" (more impaired in the RG setting compared with the DL setting).
Since it was hypothesized that participants would do better within the RG setting than within the DL session, the frequencies of worse and same outcomes were combined. Each of the four categories of discourse was then subjected to a 2 X 2 chi-square analysis to calculate the one-tailed probability of the observed frequency of better ratings versus the combined classifications of same and worse ratings.
Table 3 shows the observed frequencies of same, better, and worse ratings in each of the four discourse categories measured in the two settings. Results of chi-square analyses showed a significant preponderance of better ratings in both the narrative category (?2 = 7.5;p < .005) and the verbal category (?2 = 4.8; ? < .025). Ratings in the conversational category trended in the predicted direction (?2 = 2.7; ? < .10). Changes in the paralinguistic category were no different than predicted by chance alone.
Of greatest interest is the finding that ratings changed in the worse direction in only one participant and only in the paralinguistic category. This participant was rated the same in both settings in the other three categories. The performance of all but four participants showed the predicted effect of setting in at least two of the four discourse categories. However, only one participant showed the predicted enhancement of setting on performance in all four categories. In only one participant did setting appear to make no difference in performance. This person's ratings were unchanged in every discourse category for the two settings.
This study represents the first attempt to formally assess the effects of reminiscing on discourse and language skills in individuals with AD. The findings are consistent with the a priori hypothesis that narrative and verbal skills are improved in a less formal reminiscing setting than the more formal DL setting. Although there are design issues that limit the interpretation of data, including the small number of participants, the high level of education, and the lack of an active control, the findings of improved narrative and verba) skills during RG are intriguing.
The patterns of impairments observed in the patients with AD in this study were qualitatively consistent with those previously described in the literature. However, the magnitude of deficit was not as great. Inspection of the small sample reveals no apparent correlation between severity of dementia and frequency of beneficial effect in the RG setting. Thus, even if the sample of patients with AD was generally less impaired, the findings would still be applicable to the general AD population.
To understand these data, one must recall that the RG session, although a formal sampling condition, was initially thought to offer less structure than the DL session. Characterized by the presence of physical objects, music, videos, and often more than one participant, the structure of the RG session was probably less formal and more variable than that of the DL session. It provided the individual with AD with a variety of cues not available in the DL session.
How might this affect the patient's speech production? Given that a cardinal feature in AD is cortical neuronal loss, the patient's inability to retrieve stored information, and thus initiate conversation and carry out other aspects of discourse, is probably due to the breakdown of neural interconnections within the brain. The greater availability of cues involving multiple sensory modalities in the RG setting would maximize opportunities for cortical stimulation and the potential for accessing stored information. Thus, the facility with more conversational discourse in the RG setting, reflected by better ratings than the DL setting, might be explained in terms of the wealth of stimulation from a variety of sources provided in the RG sampling condition.
Another interpretation of ata might be that sharing memories of experiences in an environment offering multiple sensory cues may lead to communicative interactions with more cohesion, and better turn-taking and topic maintenance skills. These implications are pertinent for the caregivers of individuals with AD. Some factors tend to have a positive influence on the richness of the communicative output. These include the manner in which communication is structured; the types of cues provided; and the manner in which topics are -selected, introduced, and changed. Therefore, clinicians might find a comprehensive language rating scale useful for documenting the status of discourse production over time and within several dimensions.
The caregiver and health care provider (e.g., physician, RNC, SLP, CTRS) is reminded that "reminiscence" is the process of examining past experiences, which have been perceived as positive and meaningful. A reminiscence program provides RNs and other professional caregivers the opportunity to listen and interact with patients on a personal level. Meaningful communication and interaction contribute to the patient's sense of Ufe satisfaction and may allow for the renewal of significant Ufe events.
Such a group may begin with sharing experiences, and develop into mutually beneficial exchanges. This exchange can build trust and may help staff understanding how certain events have helped shaped patients* personalities. These exchanges may provide staff with additional insight into patient values, which may be reflected in their current behavior.
Reminiscence activities are not about the past, they are about the present. It is the direct experience of aging, the present positive interaction within the milieu. Reminiscence activities may be incorporated as an on-going process. This practice regards the quality of the interaction as one of the most important aspects. Reminiscence offers a useful tool in facilitating positive outcomes for patient-centered goals.
The disease process associated with AD causes many cognitive and linguistic skills to decline. The need for effective, efficient communicative interactions continue, however. Reminiscence activities conducted in a home-like, relaxed environment offer patients an opportunity to reflect on the past. This pilot data suggests the sharing of memories in a reminiscence setting can promote greater, more diverse social interaction enabling patients to produce qualitatively better conversational discourse.
The present investigation examined specific features of conversational discourse in a small group of patients with AD. Future studies may explore the effect of reminiscence activities on other forms of discourse, such as narrative or procedural. Comparisons may also be made between the discourse produced during other less-structured sampling conditions, such as mealtime, coffee hour, or after watching the evening news.
It would also be useful to examine the long-term effects of reminiscence activities on language performance. That is, does the language of patients with AD decline at the same rate when reminiscence activities are consistently integrated into the maintenance treatment plan in comparison to patients who are not introduced to reminiscence activities? It should be noted that the positive effects described in this pilot study were maintained for a period of at least 6 months posttesting.
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PATTERNS OF COMMUNICATION CHANCES ASSOCIATED WITH AD
PROFILE OF STUDY PARTICIPANTS
FREQUENCY OF OBSERVED CHANGES IN DISCOURSE RATINGS