Cognitive-Communication Disorders Theory questions

Includes references. Be able to identify key cognitive factors that affect communication in dementia and describe the cognitive-communication changes. Bble to evaluate the impact of dementia on psychological and social well-being. Be able to evaluate assessment approaches of communication difficulties and interpret profiles of diverse assessment methods for people with dementia. Be able to evaluate intervention approaches to the communication difficulties of people with dementia.

What are examples of common cognitive symptoms of dementia?

Short term memory impairment - may rely on others/us to act as their memory in conversation.

Difficulty thinking & reasoning.

Anxiety, nerves & depression - related to a feeling of losing control. Reduced concentration & attention.

Visual perceptual problems - making sense of what their eyes are seeing or even hallucinations.

Changes in personality and mood - might be a change/loss in social skills e.g. being able to hide your stress/ nerves.

What are common communication changes seen in someone with dementia?

Expressive language difficulties.

Receptive language difficulties.

Social difficulties.

What are the challenges of communication changes when living with dementia?

Communication changes impact on all areas of daily living for people with dementia.

Causes communication breakdown between carers, making it hard for them to cope.

Presents as behaviours which are frequently a means of communication.

Increases the prevalence of anxiety and depressions when communication attempts are unsuccessful.

What are examples of expressive language difficulties seen in people with dementia?

Word-finding difficulties.

Word substitutions/ confusion with pronouns - semantic difficulties. Reduced fluency.

Dysarthria.

Repetition of words/phrases/sounds and echolalia.

Vague, empty speech - lacking function words, hard for listener due to lack of context, could be from days, months, years ago.

Quiet speech - our brains are responsible for monitoring how loud we speak.

Continuous streams of 'nonsense' words or utterances - muddled speech - reduced intelligibility and confabulations (brain fills in the missing gaps with things that aren't necessarily plausible)

What are examples of social communication difficulties seen in people with dementia?

Difficulty initiating a new topic and maintaining a topic.

Difficulty turn-taking in conversation.

May make socially inappropriate remarks.

Reduced concentration.

Losing train of thought/ going off topic.

Frustration towards another person when not understood.

What is the psychological/ social impact of communication difficulties on the individual with dementia?

Social isolation.

Negative changes in behaviour and emotion.

Impoverished QoL.

Unmet psychological needs - Kitwood (1997) - Identity, Attachment, Inclusion, Occupation and Comfort.

Early institutionalisation.

What did Tom Kitwood contribute?

He did a lot in the understanding of person-centred dementia care.

5 Psychological needs flower.

Malignant Social Psychology: personal detractions.

Positive Person Work: personal enhancers.

Enriched model of person-centred dementia care - looks at 5 dimensions of living with Dementia.

What are the 5 psychological needs of Tom Kitwood (1997)’s flower?

Identity: feeling like yourself cognitively, what you know about yourself, continuity in your idea of self.

Attachment: feeling a connection to something outside of ourself: people, pets, objects.

Inclusion: we want to feel included in decision which impact us.

Occupation: having stuff to do, we need purpose e.g. washing - things purposeful to the indidivual.

Comfort.

What is the importance of these needs for people with CCD?

Kitwood (1997) says that the 5 psychological needs must be met to feel genuine positive regard, which is an innate human need to feel and give.

People with CCD may struggle to meet these needs themselves and so might need support to do so.

How we interact with people directly impacts how we receive these needs.

What does malignant social psychology (Kitwood, Dementia Reconsidered, 1997) describe?

Kitwood describes behaviours and attitudes that undermine the psychological needs, personhood and well-being of individuals, particularly those with dementia.

Collated into 17 interaction types that are coined ‘personal detractions’

What are examples of personal detractions which threaten COMFORT?

Intimidation.

Withholding from giving asked for attention or meeting an evident need of contact.

Outpacing: proving information/ choices too quickly.

What are examples of personal detractions which threaten IDENTITY?

Infantilisation: treating a person like a child/ patronising.

Labelling: using a label as the main way to describe a person.

Disparagement: telling a person they are worthless, incompetent or incapable.

What are examples of personal detractions which threaten ATTACHMENT?

Accusation Treachery: using deception to distract/manipulate a person.

Invalidation: failing to acknowledge the reality of a person in a situation.

What are examples of personal detractions which threaten INCLUSION?

Stigmatisation: treating people as if they were diseased/ outcasts.

Ignoring.

Banishment: sending a person away/ excluding them.

Mockery: making jokes at their expense.

What are examples of personal detractions which threaten OCCUPATION?

Disempowerment: not allowing people to use the abilities that they have.

Imposition: Forcing people to do something or denying them choice.

Disruption: intruding with something a person is doing or crudely breaking their 'frame of reference'

Objectification: treating people as if they are an object.

What does ‘positive person work’ (Kitwood, 1997) describe?

Behaviours that promote dignity, respect and the uniqueness of the person.

17 interaction types that are encouraged to meet the psychological needs and counter Kitwoods personal detractions.

Coined as ‘personal enhancers’

What are the personal enhancers that support COMFORT?

Warmth: affection, care and concern for the person.

Holding: providing safety and security for the person.

Relaxed pace: recognising the importance of helping create a relaxed atmosphere.

What are the personal enhancers that support IDENTITY?

Respect: treating the person as a valued member of society and recognising their age and experience.

Acceptance: having a positive attitude and regard for the other.

Celebration: recognising and supporting the skills and achievements of a person.

What are the person enhancers that support INCLUSION?

Recognition: meeting a person in their own uniqueness, bringing an open and unprejudiced attitude.

Including: Enabling and encouraging a person to be and feel included.

Belonging: providing a sense of acceptance in a particular setting.

Fun: accessing a free, creative way of being and using and responding to the use of fun and humour.

What are the personal enhancers that support ATTACHMENT?

Acknowledgement: recognising, accepting and supporting the person as unique and valuing them as an individual.

Genuineness: being honest and open in a way that is sensitive to the persons needs and feelings.

Validation: recognising and supporting the reality of a person.

What are the personal enhancers that support OCCUPATION?

Empowerment: letting go of control and assisting a person to discover or employ abilities and skills.

Facilitation: assessing levels of support required and providing them, no more and no less.

Enabling: encouraging a persons level of engagement within a frame of reference.

Collaboration: treating a person as a full/equal partner in what is happening.

In order to provide an enriched model of person-centred care, we must consider the 5 dimensions of the experience of living with dementia (Kitwood, 1997)…

1. Neurological Impairment

2. Health: pain, sensory impairment, mental health, neurodiversity - what are their needs?

3. Personality: impacts our approach to therapy

4. Biography: can shape conversation knowing their hobbies/ profession/ life story/ social history

5. Social Psychology: the relationship people have with others and the quality of these

What are the 3 D’s in differential diagnosis?

Dementia

Delerium

Depression

What are the characteristics of Alzheimer’s disease?

Memory impairment, especially short-term.

Word finding difficulties.

Dysexecutive impairment: difficulties with planning, reasoning, abstract thinking, flexibility, inhibition of emotions and social skills.

Decline is usually insiduous.

What are the characteristics of Vascular Dementia?

Focal communication difficulties, impacting speech, language and executive functioning.

Decline is usually step-wise.

What are the characteristics of Frontotemporal Dementia?

Progressive behaviour changes (FTD)

Progressive change in language and speech (PPA)

What are the characteristics of Lewy Body Dementia?

Attention difficulties

Hallucinations

Reduction in speech

Word finding difficulties

Motor speech disorders such as dysarthria

What are the characteristics of Korsakoff Syndrome?

Memory impairment

Confabulations

Limited insight

What are the characteristics of Progressive Supranuclear Palsy?

Dysexecutive impairment

Disinhibition

Apathy

Dysarthria

Dysphonia

What are the characteristics of Posterior Cortical Atrophy?

Progressive difficulties with reading, spelling, identifying and using common objects/ tools.

What are the 3 types of primary progressive aphasia and their characteristics (PPA)?

Semantic: Impaired naming, comprehension of words, object recognition, surface dyslexia. Strengths in grammar, fluency, accurate repetition.

Logopenic: Impaired sentence repetition, digit span repetition, phonology, empty speech, single word retrieval. Strengths in grammar, single word repetition, single word comprehension.

Non-fluent/ agrammatic: Dysfluent, hesitant, effortful speech, speech sound errors, agrammatic, impaired sentence comprehension. Strengths in single word comprehension.

What is the average age of onset for PPA?

late 50’s/ early 60’s (working age)

People with PPAs may experience depression and apathy, what might this impact?

Assessment

Intervention

Reasons for communication referrals to SLT…

To aid diagnosis

Advice and strategies for people with dementia with word finding difficulties.

Advice and strategies for family/friends/carers/staff

“Challenging behaviour”

Reasons for SLT to carry out communication ax with someone with dementia…

To differentiate between diagnoses.

To identify areas of strength.

To identify areas that might benefit from intervention.

To provide personalised support and education.

To enable us to set personalised goals.

As a baseline for measuring progress and outcomes.

What different types of assessment can we use?

Case history

Standardised tests

Informal assessment, checklists and rating scales

Direct observation

Conversation

What information do you need from a case history?

Medical history

Social history

Communication history

Environmental evaluation

Remember enriched model of care: neurological impairment; health; biography; personality; social psychology

What are examples of standardised tests…

1. Amsterdam Nijmegen Everyday Language Test (Blomert et al., 1994)

2. Arizona Battery for Communication Disorders in Dementia (Bales & Tomoeda, 1993).

3. Assessment for Living with Aphasia Toolkit (Kagan et al., 2007)

4. Boston Naming Test (Kaplan et al., 2000)

5. Cognitive linguistic quick test (Helm-Eastbrooks, 2001)

6. Comprehensive Aphasia Test (Swinburn, Porter & Howard, 2004)

7. Comprehensive Assessment of Acceptance and Commitment Therapy Process (CompACT)

8. Functional Linguistic Communication Inventory (Bayles & Tomoeda, 1994)

9. Mount Wilga High Level Language Test (Simpson et al., 2006)

10. Pyramids and Palm Trees (Howard & Patterson, 1992)

What are components of discourse analysis that can be used as an informal assessment?

Explanation of an event or story (narrative) e.g. Cinderella

Explanation of how to complete a task (procedural)

Discussion of a topic (conversational)

Description of a stimulus e.g. cookie theft from Boston

Diagnostic Aphasia Examination (descriptive)

What are other methods of informal assessment?

Talking Mats

Pragmatics Profile (Dewart & Summer, 1996)

Holden Communication Scale (Holden & Woods, 1995)

Well-being scales e.g. DEMQOL (Smith et al., 2005) and QUALID (Weiner et al., 2000)

What are methods of observational assessment?

Social Communication Skills Checklist

Bradford well-being profile

informal observation of a specific area of concern

Dementia Care Mapping

When choosing your assessment, what do you need to consider?

What are you trying to find out

What will and wont the assessment tell you

Are the questions age appropriate

Who was the assessment standardised with

Will it change your recommendations

Are there quicker or less invasive ways to find out the same information

Is this a priority for the individual