Conversational repair by individuals with dementia of the Alzheimer's type

Communication Patterns and Characteristics of Family Caregivers and Persons Living With Dementia: Secondary Analysis of Video Observation

BACKGROUND

It is essential to characterize communication patterns for better health outcomes for family caregivers and persons living with dementia.

OBJECTIVE

This study aimed to examine the relationships between communication patterns and the characteristics of dyads of family caregivers and persons living with dementia.

METHODS

A secondary analysis was conducted using 75 video-recorded home care observations from 19 dyads. Participant characteristics and caregiver burden, depression, and sense of competence were collected from the parent study. The video-recorded dyadic communication patterns were assessed using a coding scheme developed based on Communication Accommodation Theory and Classical Test Theory. The relative frequency of the communication patterns was compared between groups.

RESULTS

Overall, 8311 caregiver and 8024 care recipient communication behaviors were observed. Caregiver communication patterns were categorized as facilitative, disabling, and neutral. Care recipient communication patterns were categorized as engaging, challenging, and neutral. Caregiver gender, care recipient gender, care recipient education level, dementia diagnosis length, types of dementia, dyadic gender difference, burden, depression, and competence of caregiver, and types of communication were significantly associated with caregiver communication. Dementia diagnosis length, caregiver competence, dyadic gender difference, and types of communication were significantly associated with care recipient communication.

CONCLUSIONS

The findings demonstrated different communication patterns depending on individual and dyad characteristics and evidence for dyadic communication support to promote meaningful interaction for persons living with dementia. Further analysis is needed to identify mediating factors and causal relationships.

Keeping the conversation going: How progressivity is prioritised in co-remembering talk between couples impacted by dementia

This article explores how partners keep the conversation going with people living with dementia (PLWD) when speaking about shared memories. Remembering is important for PLWD and their families. Indeed, memory loss is often equated with identity loss. In conversation, references to shared past events (co-rememberings) can occasion interactional trouble if memories cannot be mutually recalled. This article analyses partners' interactional practices that enable progressivity in conversations about shared memories with a PLWD. In previous research, both informal and formal carers have reported that they can find interacting with PLWD difficult. Identifying practices used by partners is one way to begin addressing those difficulties. Analytical findings are based on over 26 hours of video data from domestic settings where partners have recorded their interactions with their spouse/close friend who is living with dementia. The focus is on 14 sequences of conversation about shared memories. We show how particular practices (candidate answers, tag questions and single-party memory of a shared event) structure the interaction to facilitate conversational progression. When partners facilitate conversational progressivity, PLWD are less likely to experience stalls in conversation. Our findings suggest the actual recall of memory is less relevant than the sense of shared connection resulting from the conversational activity of co-remembering, aiding maintenance of individual and shared identities. These findings have relevance for wider care settings.

Determining Evidence for Family Caregiver Communication: Associating Communication Behaviors With Breakdown and Repair

BACKGROUND AND OBJECTIVES

Communication is fundamental for dementia care. The trouble source repair (TSR) framework can identify strategies that facilitate or impede communication in dyadic interactions.

RESEARCH DESIGN AND METHODS

A secondary analysis of videos (N = 221) from a clinical trial of a family caregiver telehealth intervention was analyzed using sequential behavioral coding of communication behaviors and breakdowns for 53 caregiver and person with dementia dyads. Coded data from 3,642 30-s observations were analyzed using penalized regression for feature selection followed by Bayesian mixed-effects modeling to identify communication strategies associated with communication breakdown and repair.

RESULTS

Breakdown (coded as 0) was associated with caregivers changing topic (median = -11.45, 95% credibility interval [CrI; -24.34, -4.37]), ignoring (median = -11.49, 95% CrI [-24.49, -4.72]), giving commands (median = -10.74, 95% CrI [-24.22, -3.38]), and taking over the task (median = -4.06, 95% CrI [-7.28, -1.77]). Successful repair of breakdown was associated with verbalizing understanding (median = 0.46, 95% CrI [0.09, 0.86]), tag questions, (median = 2.4, 95% CrI [0.33, 5.35]), and silence (median = 0.78, 95% CrI [0.42, 1.15]) and negatively associated with ignoring and changing topic (median = -3.63, 95% CrI [-4.81, -2.57] and -2.51 [-3.78, -1.33], respectively).

DISCUSSION AND IMPLICATIONS

The TSR was effective in identifying specific communication strategies to avoid (changing topic, ignoring, commands, and taking over the task) and to use to repair breakdown (verbalize understanding, tag questions, and silence). Future research is needed to test these strategies and explore the potential effects of dementia stage, diagnosis, and dyad characteristics in additional samples. Behavioral coding provides evidence of communication best practices as a basis for family caregiver communication training.

Conversational repair in individuals with Alzheimer disease

PURPOSE

many of the difficulties that usually arise in colloquial conversation may be repaired as the interaction develops. Conversational repair is a linguistic strategy that indicates evidence of the partners' abilities to promote necessary mutual understanding for effective communication. This study aims to analyze the oral text repairs of 10 older adults with Alzheimer's dementia (AD) and 10 older adults without dementia, as well as to verify whether they are a useful element for language disorders identification in AD.

METHODS

autobiographical interview and application of items of the MetAphAs protocol were proposed. Data were analyzed based on the methodology of conversational analysis.

RESULTS

the results indicated that self-initiated repairs are frequent in both groups, although subjects with AD made more use of inadequate repairs, which did not favor mutual understanding. Hetero-repairs occurred most frequently in conversations with individuals with AD, suggesting the need for interlocutor's intervention to adjust a specific utterance.

CONCLUSION

this research has shown that using repair strategies is sensitive to individuals with AD cognitive performance.

Developing Behavioral Coding to Understand Family Communication Breakdown in Dementia Care

Communication breakdown is a challenge for family caregivers of persons living with dementia. We adapted established theory and scales for computer-assisted behavioral coding to characterize caregiver communication for a secondary analysis. We developed verbal, nonverbal, and breakdown coding schemes and established reliability (κ > .85). Within the 221 family caregiving videos analyzed, 55% of exchanges were interactive, 30% were silence, 4% consisted of talking to self or others, and 8% included a breakdown. An average of 2.4 (SD = 1.9) breakdowns occurred per observation and were successfully resolved 85% of the time, with 31% being resolved most successfully following only one flag and repair strategy. Caregivers were the primary speakers (67%); their communication preceded most breakdown (65%), and they primarily initiated the repairs after a breakdown (70%). Common repair strategies included clarifications (31%), asking questions (24%), and repeating information (24%). Associations between communication strategies and repair success will provide evidence for caregiver training.

Dyadic interactions and physical and social environment in dementia mealtime care: a systematic review of instruments

Using valid instruments to measure dyadic interactions and physical and social environment during mealtime care of persons with dementia is critical to evaluate the process, fidelity, and impact of mealtime interventions. However, the characteristics and quality of existing instruments remain unexplored. This systematic review described the characteristics and synthesized the psychometric quality of instruments originally developed or later modified to measure mealtime dyadic interactions and physical and/or social dining environment for people with dementia, on the basis of published reports between January 1, 1980 and December 31, 2020. We identified 26 instruments: 17 assessed dyadic interactions, one assessed physical environment, and eight assessed physical and social environment. All instruments were used in research and none in clinical practice. All instruments were observational tools and scored as having low psychometric quality, except for the refined Cue Utilization and Engagement in Dementia (CUED) mealtime video-coding scheme rated as having moderate quality. Reasons for low quality are the use of small samples compared with the number of items, limited psychometric testing, and inadequate estimates. All existing tools warrant further testing in larger diverse samples in varied settings and validation for use in clinical practice. The refined CUED is a potential tool for use and requires testing in direct on-site observations.

When an Aging Spouse Has Dementia: Impact of a Home-Based Intervention on Marital Communication

Researchers tested the impact of a 10-week intervention, Communicating About Relationships and Emotions (CARE), on misunderstandings and resolutions in marital communication between spouses affected by dementia. A single group, repeated-measures secondary analysis was used to analyze 65 transcribed dyadic conversations for misunderstandings, resolutions, number of caregiver and care receiver words over 10 sessions. Misunderstandings continued to occur over 10 weeks, but resolution of misunderstandings increased (β = 5.75, p = .044). Increased caregiver words escalated misunderstandings. Dementia-related language impairments threaten relationships by creating frustration and stress in older couples. With CARE, spouse caregivers can improve resolution of misunderstandings.

Gesture, communication, and adult acquired hearing loss

Nonverbal communication, specifically hand and arm movements (commonly known as gesture), has long been recognized and explored as a significant element in human interaction as well as potential compensatory behavior for individuals with communication difficulties. The use of gesture as a compensatory communication method in expressive and receptive human communication disorders has been the subject of much investigation. Yet within the context of adult acquired hearing loss, gesture has received limited research attention and much remains unknown about patterns of nonverbal behaviors in conversations in which hearing loss is a factor. This paper presents key elements of the background of gesture studies and the theories of gesture function and production followed by a review of research focused on adults with hearing loss and the role of gesture and gaze in rehabilitation. The current examination of the visual resource of co-speech gesture in the context of everyday interactions involving adults with acquired hearing loss suggests the need for the development of an evidence base to effect enhancements and changes in the way in which rehabilitation services are conducted.

A Conversational Robot for Older Adults with Alzheimer’s Disease

Amid the rising cost of Alzheimer’s disease (AD), assistive health technologies can reduce care-giving burden by aiding in assessment, monitoring, and therapy. This article presents a pilot study testing the feasibility and effect of a conversational robot in a cognitive assessment task with older adults with AD. We examine the robot interactions through dialogue and miscommunication analysis, linguistic feature analysis, and the use of a qualitative analysis, in which we report key themes that were prevalent throughout the study. While conversations were typically better with human conversation partners (being longer, with greater engagement and less misunderstanding), we found that the robot was generally well liked by participants and that it was able to capture their interest in dialogue. Miscommunication due to issues of understanding and intelligibility did not seem to deter participants from their experience. Furthermore, in automatically extracting linguistic features, we examine how non-acoustic aspects of language change across participants with varying degrees of cognitive impairment, highlighting the robot’s potential as a monitoring tool. This pilot study is an exploration of how conversational robots can be used to support individuals with AD.

Conversational trouble and repair in dementia: Revision of an existing coding framework

A decline in the effectiveness of everyday conversation is often observed for people with dementia. This study explored conversational trouble and repair between people with dementia residing in residential care and professional care staff. The aim was to examine the utility of an existing conversational trouble and repair framework by Watson, Carter and Chenery (1999) in a comparatively larger sample. Twenty conversations were coded for dementia-specific trouble and repair; however, the original framework could not adequately accommodate the variety of trouble and repair within the dataset. The data was subsequently used to inform a revised framework, which captures a wide spectrum of trouble and repair in dementia and offers more precise codes to researchers and clinicians working with this clinical population. Examples of divergent coding strategies between the original and revised framework are provided as well as examples of trouble and repair patterns observed in both carers and people with dementia.

Assessing cognitive communication skills in dementia: a scoping review

BACKGROUND

Cognitive communication difficulties are a characteristic feature of dementia. These deficits have negative effects on all aspects of daily life. Yet, there are few options for standardized assessment of cognitive communication skills in people with dementia.

AIMS

To review published cognitive-communication assessments to determine what psychometrically sound assessments exist that are applicable to all people with dementia.

METHODS & PROCEDURES

A scoping review of the literature was conducted using an established scoping review model. Cognitive-communication assessments validated in English with people with dementia were sought. A comprehensive search of eight relevant electronic databases was undertaken. Two reviewers independently analysed and assessed the psychometric quality of instruments that met inclusion criteria.

OUTCOMES & RESULTS

Four cognitive-communication assessments were included in the review. Although psychometrically sound, none was suitable for administration at all stages of dementia. Only one was validated for different dementia types. None included subtests for evaluation of conversation ability, and none involved the evaluation of communication partners' communication.

CONCLUSIONS & IMPLICATIONS

There are limited options for standardized communication assessment for individuals with dementia and their communication partners. Directions for the development of new measures are provided to facilitate research and improve clinical practice.

Toward the Development of SMART Communication Technology: Automating the Analysis of Communicative Trouble and Repair in Dementia

BACKGROUND AND OBJECTIVES

Communication difficulties have been reported as one of the most stress-inducing aspects of caring for people with dementia. Notably, with disease progression comes an increase in the frequency of communication difficulty and a reduction in the effectiveness of attempts to remedy breakdowns in communication. The aim of the current research was to evaluate the utility of an automated discourse analysis tool (i.e., Discursis) in distinguishing between different types of trouble and repair signaling behaviors, demonstrated within conversations between people with dementia and their professional care staff.

RESEARCH DESIGN AND METHODS

Twenty conversations between people with dementia and their professional care staff were human-coded for instances of interactive/noninteractive trouble and typical/facilitative repair behaviors. Associations were then examined between these behaviors and recurrence metrics generated by Discursis.

RESULTS

Significant associations were identified between Discursis metrics, trouble-indicating, and repair behaviors.

DISCUSSION AND IMPLICATIONS

These results suggest that discourse analysis software is capable of discriminating between different types of trouble and repair signaling behavior, on the basis of term recurrence calculated across speaker turns. The subsequent recurrence metrics generated by Discursis offer a means of automating the analysis of episodes of conversational trouble and repair. This achievement represents the first step toward the future development of an intelligent assistant that can analyze conversations in real time and offers support to people with dementia and their carers during periods of communicative trouble.

Familiar communication partners' facilitation of topic management in conversations with individuals with dementia

BACKGROUND

Language and memory impairments affect everyday interactions between individuals with dementia and their communication partners. Impaired topic management, which compromises individuals' construction of relevant, meaningful discourse, is commonly reported amongst individuals with dementia. Currently, limited empirical evidence describes the sequential patterns of behaviour comprising topic-management practices in everyday conversation between individuals with dementia and their communication partners.

AIMS

To describe the sequential patterns of behaviour relating to the manifestation of topic-management impairments and facilitative behaviours in everyday interactions between individuals with dementia and their familiar communication partners (FCPs).

METHODS & PROCEDURES

Three 20-min conversations between individuals with moderate to severe dementia and their FCPs were recorded. Conversation Analysis was used to examine sequences in which topic-management appeared to be impaired.

OUTCOMES & RESULTS

Conversational behaviours that reflected a difficulty in contributing on-topic talk were pervasive in the talk of the three individuals with dementia. FCPs responded to these conversational difficulties by using two categories of facilitative behaviours. The first involved responding to an individual with dementia's explicit repair-initiation by performing repair. In the second category, explicit repair-initiation was absent; instead, the distance of the conversational difficulty from the prior topic-shifting turn mediated the form and outcome of the FCPs' facilitative behaviours. Each category successfully facilitated the individual with dementia to contribute on-topic talk.

CONCLUSIONS & IMPLICATIONS

The findings contribute to a growing understanding of topic-management abilities in everyday interactions involving individuals with dementia. Individuals with dementia took a proactive role in eliciting topic-management support. The FCPs responded with turns that facilitated the individuals with dementia to talk on-topic. Clinically, the results support and extend the current topic-management recommendations available in communication partner training programmes, and promote conversations which attend to the personhood of the individual with dementia.

Collaboration, trouble and repair in multiparty interactions involving couples with dementia or aphasia

PURPOSE

The aim of the present study was to identify problems with communication with persons with aphasia and persons with dementia in a collaborative interview setting with their significant others. In particular, to compare interactional practices used in order to resolve problems caused by specific symptoms.

METHOD

Five persons with aphasia and five persons with dementia and their spouses participated in the study. Interviews were carried out couple by couple, and the interviews had a task-oriented character. The interviews were video and audio recorded. All interviews were transcribed. From the transcriptions categorisations according to previous literature were made.

RESULT

The results demonstrated that repair sequences were frequent in interaction involving people with aphasia (PWA), and even more so in interaction involving persons with dementia (PWD). In general, it was the PWA/PWD that initiated the repair sequence more often than the spouse, thus keeping the general rule of a preference for self-initiated repair compared to other-initiated repair.

CONCLUSION

The active involvement of the conversational partners in trouble solving sequences in interaction with PWA/PWD demonstrated in the present study indicates that the interactional style of the conversational partner to PWA/PWD important. This implies that conversation partner training programmes would be useful both for PWA and for PWD.

Preliminary Psychometric Properties of the Verbal and Nonverbal Interaction Scale: An Observational Measure for Communication in Persons with Dementia

Little attention has been given to sociable/unsociable communication in persons with dementia despite the importance of these behaviors in maintaining engagement in marital relationships. An observational measure of verbal and nonverbal communication in persons with dementia (Verbal and Nonverbal Interaction Scale-CR) who were engaged in conversations with spouses was tested for reliability and validity. Married persons with dementia were video-recorded at home conversing with spouses over 10 weeks (N = 118 recordings). Reliability [inter-coder (.92), test-retest (r =.61-.77), internal consistency (α =.65 -.79)] were adequate. Following an intervention, the Verbal and Nonverbal Interaction Scale-CR predicted improved communication over 10 weeks. The ratio of sociable to unsociable communication improved by 4.46 points per session [β = 4.46, t(10) = 1.96, p =.039]. VNVIS-CR is recommended to describe sociable and unsociable communication in persons with dementia as they engage in conversations with spouses.

Communication between individuals with dementia and their caregivers during activities of daily living

Much previous research has focused on linguistic factors that can lead to communication breakdown in caregiver-patient interactions. However, the impact of such linguistic deficits on communication may vary depending on the context, goals, and complexity of the interaction. As a result, the likelihood of experiencing communication problems is expected to differ across different activities. In the present study, family caregivers of persons with dementia were asked to discuss communication challenges that they have experienced in a range of daily activities in the home. Four focus groups, involving a total of 22 caregivers, were conducted in community settings. The main goal of the focus groups was to identify specific daily activities in the home in which caregivers most often experience communication problems. The content of the focus groups was audio recorded and transcribed, and then coded and analyzed using qualitative and quantitative analytic techniques. The analyses focused on identifying trends across caregivers in which particular activities were noted as being prone to communication breakdown at different stages of the disease. Information about which activities are most communicatively challenging should assist caregivers in preparing for and adapting to these changes.

IV. When May Calls Home

Using conversation analysis, this article analyses the opening moments of naturally occurring telephone conversations between a woman with Alzheimer's disease and her daughter and son-in-law. Drawing on the large body of work on ordinary conversational openings between adults without cognitive impairments, we show that this Alzheimer's patient is a virtually fully competent interactant in the routinized aspects of call-openings (summons—answer, recognitions, greetings, `howaryou', and the pre-emption of `how- aryou's to do urgency). We show, however, that in the very act of displaying these cognitive and social competencies in conversation with her daughter, she also reveals serious memory loss, which has devastating consequences for the mother—daughter relationship. In developing this research, we hope to enable families better to cope with the consequences of Alzheimer's disease.

Speech Interaction with Personal Assistive Robots Supporting Aging at Home for Individuals with Alzheimer’s Disease

Increases in the prevalence of dementia and Alzheimer’s disease (AD) are a growing challenge in many nations where healthcare infrastructures are ill-prepared for the upcoming demand for personal caregiving. To help individuals with AD live at home for longer, we are developing a mobile robot, called ED, intended to assist with activities of daily living through visual monitoring and verbal prompts in cases of difficulty. In a series of experiments, we study speech-based interactions between ED and each of 10 older adults with AD as the latter complete daily tasks in a simulated home environment. Traditional automatic speech recognition is evaluated in this environment, along with rates of verbal behaviors that indicate confusion or trouble with the conversation. Analysis reveals that speech recognition remains a challenge in this setup, especially during household tasks with individuals with AD. Across the verbal behaviors that indicate confusion, older adults with AD are very likely to simply ignore the robot, which accounts for over 40% of all such behaviors when interacting with the robot. This work provides a baseline assessment of the types of technical and communicative challenges that will need to be overcome for robots to be used effectively in the home for speech-based assistance with daily living.

Problematic topic transitions in dysarthric conversation

PURPOSE

This study examined the nature of topic transition problems associated with acquired progressive dysarthric speech in the everyday conversation of people with motor neurone disease.

METHOD

Using conversation analytic methods, a video collection of five naturally occurring problematic topic transitions was identified, transcribed and analysed. These were extracted from a main collection of over 200 other-initiated repair sequences and a sub-set of 15 problematic topic transition sequences. The sequences were analysed with reference to how the participants both identified and resolved the problems.

RESULT

Analysis revealed that topic transition by people with dysarthria can prove problematic. Conversation partners may find transitions problematic not only because of speech intelligibility but also because of a sequential disjuncture between the dysarthric speech turn and whatever topic has come prior. In addition the treatment of problematic topic transition as a complaint reveals the potential vulnerability of people with dysarthria to judgements of competence.

CONCLUSION

These findings have implications for how dysarthria is conceptualized and how specific actions in conversation, such as topic transition, might be suitable targets for clinical intervention.

Auditory and Visual Cues for Topic Maintenance with Persons Who Exhibit Dementia of Alzheimer’s Type

This study compared the effectiveness of auditory and visual redirections in facilitating topic coherence for persons with Dementia of Alzheimer's Type (DAT). Five persons with moderate stage DAT engaged in conversation with the first author. Three topics related to activities of daily living, recreational activities, food, and grooming, were broached. Each topic was presented three times to each participant: once as a baseline condition, once with auditory redirection to topic, and once with visual redirection to topic. Transcripts of the interactions were scored for overall coherence. Condition was a significant factor in that the DAT participants exhibited better topic maintenance under visual and auditory conditions as opposed to baseline. In general, the performance of the participants was not affected by the topic, except for significantly higher overall coherence ratings for the visually redirected interactions dealing with the topic of food.

Communicative strategies used by spouses of individuals with communication disorders related to stroke-induced aphasia and Parkinson's disease

BACKGROUND

A communicative disability interferes with the affected person's ability to take active part in social interaction, but non-disabled communication partners may use different strategies to support communication. However, it is not known whether similar strategies can be used to compensate for different types of communicative disabilities, nor what factors contribute to the development of a particular approach by communication partners.

AIMS

To develop a set of categories to describe the strategies used by communication partners of adults who have problems expressing themselves due to neurogenic communicative disabilities. The reliability of assessment was a particular focus.

METHODS & PROCEDURES

The material explored consisted of 21 video-recorded everyday conversations involving seven couples where one spouse had a communicative disability. Three of the dyads included a person with dysarthria and anomia related to later stages of Parkinson's disease, while four of them included a person with stroke-induced aphasia involving anomia. First a qualitative interaction analysis was performed to explore the strategies used by the communication partners when their spouses had problems expressing themselves. The strategies were then categorized, the reliability of the categorizations was explored and the relative frequency of the various strategies was examined.

OUTCOMES & RESULTS

The analysis of the conversational interactions resulted in a set of nine different strategies used by the communication partners without a communicative disability. Each of these categories belonged to one of three overall themes: No participation in repair; Request for clarification or modification; and Providing candidate solutions. The reliability of the categorization was satisfactory. There were no statistically significant differences between diagnoses in the frequency of use of strategies, but the spouses of the persons with Parkinson's disease tended to use open-class initiations of repair more often than the spouses of the persons with aphasia.

CONCLUSIONS & IMPLICATIONS

The types of strategies used by spouses of persons with neurogenic communicative disabilities seem to be more strongly associated with individual characteristics of communicative ability than with the type of disorder involved. The set of categories developed in this study needs to be trialled on larger groups of participants, and modified if and as necessary, before it can be regarded as a valid system for the description of such strategies in general. Once this has been done it may become a useful instrument in the assessment of the strategies used by communication partners of individuals with communicative disabilities.

Matched and mismatched appraisals of the effectiveness of communication strategies by family caregivers of persons with Alzheimer's disease

BACKGROUND

Communication problems stemming from Alzheimer's disease (AD) often result in misunderstandings that can be linked with problem behaviours and increased caregiver stress. Moreover, these communication breakdowns also can result either from caregivers' use of ineffective communication strategies, which paradoxically are perceived as helpful, or can occur as a result of not using effective communication strategies that are perceived as unhelpful.

AIMS

The two primary aims were to determine the effectiveness of strategies used to resolve communication breakdowns and to examine whether caregivers' ratings of strategy effectiveness were consistent with evidence from video-recorded conversations and with effective communication strategies documented in the literature.

METHODS & PROCEDURES

Twenty-eight mealtime conversations were recorded using a sample of 15 dyads consisting of individuals with early, middle and late clinical-stage AD and their family caregivers. Conversations were analysed using the trouble-source repair paradigm to identify the communication strategies used by caregivers to resolve breakdowns. Family caregivers also rated the helpfulness of communication strategies used to resolve breakdowns. Analyses were conducted to assess the overlap or match between the use and appraisals of the helpfulness of communication strategies.

OUTCOMES & RESULTS

Matched and mismatched appraisals of communication strategies varied across stages of AD. Matched appraisals by caregivers of persons with early-stage AD were observed for 68% of 22 communication strategies, whereas caregivers of persons with middle- and late-stage AD had matched appraisals for 45% and 55% of the strategies, respectively. Moreover, caregivers of persons with early-stage AD had matched appraisals over and above making matched appraisals by chance alone, compared with caregivers of persons in middle- and late-stage AD.

CONCLUSIONS & IMPLICATIONS

Mismatches illustrate the need for communication education and training, particularly to establish empirically derived evidence-based communication strategies over the clinical course of AD.

A family living with Alzheimer’s disease: The communicative challenges

Alzheimer’s disease irrevocably challenges a person’s capacity to communicate with others. Earlier research on these challenges focused on the language disorders associated with the condition and situated language deficit solely in the limitations of a person’s cognitive and semantic impairments. This research falls short of gaining insight into the actual interactional experiences of a person with Alzheimer’s and their family. Drawing on a UK data set of 70 telephone calls recorded over a two-and-a-half year period (2006–2008) between one elderly woman with Alzheimer’s disease, and her daughter and son-in-law, this paper explores the role which communication (and its degeneration) plays in family relationships. Investigating these interactions, using a conversation analytic approach, reveals that there are clearly communicative difficulties, but closer inspection suggests that they arise due to the contingencies that are generated by the other’s contributions in the interaction. That being so, this paper marks a departure from the traditional focus on language level analysis and the assumption that deficits are intrinsic to the individual with Alzheimer’s, and instead focuses on the collaborative communicative challenges that arise in the interaction itself and which have a profound impact on people’s lives and relationships.

Quantitative analysis of formal caregivers' use of communication strategies while assisting individuals with moderate and severe Alzheimer's disease during oral care

This cross-sectional observational study examined formal caregivers' use of task-focused and social communication strategies while assisting individuals with moderate and severe Alzheimer's disease residing in a long-term care facility during a basic activity of daily living: toothbrushing. Thirteen formal caregiver-resident dyads were observed during a total of 78 separate toothbrushing sessions. All caregiver utterances occurring during the task were transcribed and coded for type of communication strategy utilizing a multidimensional observational coding scheme, which was developed a priori. Overall, the majority of residents, irrespective of disease severity, successfully completed toothbrushing with the support of caregiver assistance. Caregivers assisting residents with moderate and severe AD were found to use a variety of communication strategies, with task-focused strategies accounting for the majority of use. For the most part, the communicative strategies employed did not differ across disease severity. However, some differences were identified including the use of one proposition, paraphrased repetition, using the resident's name, and provision of full assistance, with these strategies being used more often when assisting individuals with severe AD. This study adds to the emerging literature supporting the use of specific communication strategies while assisting residents with AD during the completion of daily tasks.

LEARNING OUTCOMES

From reviewing this study, readers will be able to identify a variety of communication strategies, both task-focused and relational, that formal caregivers utilize while assisting residents with moderate and severe Alzheimer's disease (AD) during a basic activity of daily living. Furthermore, the reader will be able to distinguish between communication strategies that are optimal when assisting individuals with moderate AD as compared to assisting individuals with severe AD.

Examining success of communication strategies used by formal caregivers assisting individuals with Alzheimer's disease during an activity of daily living

PURPOSE

To examine how formal (i.e., employed) caregivers' use verbal and nonverbal communication strategies while assisting individuals with moderate to severe Alzheimer's disease (AD) during the successful completion of an activity of daily living (ADL). Based on the literature, the authors hypothesized that caregivers' use of 1 proposition, closed-ended questions, and repetition would be of most benefit.

METHOD

Twelve caregiver-AD dyads participated in this observational study. Each dyad was videorecorded on 6 separate occasions while completing handwashing. Handwashing sessions were transcribed and systematically coded for the use of communication strategies during completion of the ADL.

RESULTS

Caregiver-AD dyads successfully completed 90% of all handwashing sessions, and caregivers employed a variety of communication strategies. Consistent with our hypotheses, during successful task completion, caregivers most frequently provided individuals with AD with 1 direction or idea (i.e., proposition) at a time, closed-ended questions, and paraphrased repetition. Caregivers also frequently used encouraging comments and the resident's name during the task; however, use of these strategies was not correlated to task success rate.

CONCLUSION

This study adds to the limited body of evidence supporting the use of specific communication strategies by caregivers assisting individuals with moderate to severe AD during successful completion of ADLs.

Relationships between appraisals of caregiver communication strategies and burden among spouses and adult children

BACKGROUND

The purpose of this study was to investigate the impact of caregivers' appraisals of the effectiveness of their own communication strategies on caregiver burden when caring for family members with Alzheimer's disease (AD).

METHODS

Family caregivers (N = 84) of participants with AD completed questionnaires appraising communication strategies, problem behaviors, and levels of three types of burden.

RESULTS

Hierarchical linear regression models revealed that effective strategies and kinship status were significantly linked with stress burden, whereas effective strategies and problem behaviors were significantly related to relationship burden. Cognitive status of participants with AD significantly predicted objective burden. Caregivers who rated effective strategies as helpful were more likely to experience lower levels of stress and relationship burden.

CONCLUSIONS

Findings provide preliminary support for understanding mechanisms by which the appraisals of communication strategies influence caregiver burden and justify testing empirically derived communication interventions.

Humour, irony and sarcasm in severe Alzheimer's dementia – a corrective to retrogenesis?

Retrogenesis is claimed to be the process by which degenerating mechanisms in the brain, as found in Alzheimer's disease (AD), reverse the order of acquisition of functions, including language, in normal child development. In FAST (Functional Assessment Staging of Alzheimer's disease) stages of AD are translated into corresponding developmental ages. Humour, irony and sarcasm are communicative strategies linked to meta-linguistic abilities developed late in childhood. If found in the conversation of people with moderately severe AD according to FAST, this could be an indication of problems in the FAST scale and subsequently in the concept of retrogenesis concerning speech and language abilities. Comprehensive, open-ended, naturalistic conversations between three nursing home residents with moderately severe AD according to FAST and their professional care-givers were analysed with concepts developed in linguistics as to the occurrence of humour, irony and sarcasm. Although the data material was limited, the findings indicate an unexpected communicative competence of the three participants. This is a corrective to retrogenesis and a caveat for poor expectations of intelligible conversations with demented people for professionals and the people they advise. Implications for research strategies and for the general knowledge of communicative competence in AD are addressed in the discussion section, and possible ways of elucidating deterioration of speech and language abilities in AD are suggested.

A tutorial on multiblock discriminant correspondence analysis (MUDICA): a new method for analyzing discourse data from clinical populations

PURPOSE

In communication disorders research, clinical groups are frequently described based on patterns of performance, but researchers often study only a few participants described by many quantitative and qualitative variables. These data are difficult to handle with standard inferential tools (e.g., analysis of variance or factor analysis) whose assumptions are unfit for these data. This article presents multiblock discriminant correspondence analysis (MUDICA), which is a recent method that can handle datasets not suited for standard inferential techniques.

METHOD

MUDICA is illustrated with clinical data examining conversational trouble-source repair and topic maintenance in dementia of the Alzheimer's type (DAT). Seventeen DAT participant/spouse dyads (6 controls, 5 participants with early DAT, 6 participants with moderate DAT) produced spontaneous conversations analyzed for co-occurrence of trouble-source repair and topic maintenance variables.

RESULTS

MUDICA found that trouble-source repair sequences and topic transitions are associated and that patterns of performance in the DAT groups differed significantly from those in the control group.

CONCLUSION

MUDICA is ideally suited to analyze language and discourse data in communication disorders because it (a) can identify and predict clinical group membership based on patterns of performance, (b) can accommodate few participants and many variables, (c) can be used with categorical data, and (d) adds the rigor of inferential statistics.

The Use of Conversational Repairs by African American Preschoolers

Purpose

This study aimed to describe the types and frequency of conversational repairs used by African American (AA) children in relationship to their geographic locations and levels of performance on commonly used speech-language measures.

Method

The strategies used to initiate repairs and respond to repair requests were identified in audiovisual records of spontaneous speech sampled from 120 Head Start students in Michigan ( n = 69) and Louisiana ( n = 51) at 3 years of age. The 30–40-min samples were elicited with common stimuli and activities while the children interacted with an adult examiner.

Results

All participants initiated repairs and responded to examiner requests for conversational repairs. Some repair strategies were observed more often than others. The frequency, but not the types, of some of the strategies used varied significantly with participant location and level of speech-language performance.

Conclusion

AA children used the same types of conversational repair strategies that have been observed among young speakers of Standard English varieties.

Clinical Implication

Use of conversational repairs should be included among the pragmatic behaviors expected for 3-year-old AA children.

Self-referential tags in the discourse of people with Alzheimer's disease

In a study of the discourse of 100 people with Alzheimer's disease treated for 12 months with donepezil, we observed that, as a group, they used a form of tag, described here as a self-referential tag (SRT), 14 times more frequently than did caregivers. Patients use SRTs to check propositions dependent on episodic memory as in I haven't seen the doctor recently, have I? and to monitor information flow as in I told you that already, didn't I? Based on criteria developed for distinguishing checking from monitoring tags, we document the type and frequency of patients' SRT use in the ACADIE corpus and analyze these in relation to standard measures of cognitive function (Mini Mental State Exam and Alzheimer's Disease Assessment Scale-cognitive sub-scale) at baseline and 12 months. Patients using monitoring SRTs (N=31), with or without checking SRTs, show significantly better cognitive test scores at 12 months, than are seen in patients who never use tags (N=29), or who only use checking tags (N=40). SRT use may be an independent measure of potential treatment responsiveness.

Lucidity in a woman with severe dementia related to conversation. A case study

AIMS AND OBJECTIVES

The aim of this study was to explore the presence of lucidity in a woman with severe dementia during conversations and whether it occurred when conversational partners or the woman with severe dementia initiated the conversation topics about the present, past or future time and whether she was presented with support or demands during the conversation.

BACKGROUND

Communication problems as well as episodes of lucidity in people with dementia are reported in the literature.

DESIGN

A researcher held 20 hours of conversation with a woman with severe dementia. A daughter participated for about three and a half hours. The conversation was tape-recorded and transcribed verbatim.

METHODS

The text was divided into units of analysis. Each unit of analysis was then assessed separately and discussed among the authors. Chi-square tests and logistic regression analysis were performed. An ethics committee approved the study.

RESULTS

The woman as initiator of the conversation topic and support to the women during conversation from the conversation partner were found to be the most significant factors explaining lucidity, while conversation about the present or past time showed no connection with lucidity. Very few topics (n = 7) concerned future time and they were not used in the statistical analysis. The researcher initiated 41%, the woman 43% and the daughter 16% of the topics. Support was registered in 49%, demands in 15% and both support and demands in 16% of the units of analysis. There were 58% topics about present and 40% about the past time.

CONCLUSIONS

The presented study is a case study and the results cannot be generalized. For the woman with severe dementia, lucidity was promoted by the conversational parties carefully focusing on conversation topics initiated by the woman while supporting her during conversation.

RELEVANCE TO CLINICAL PRACTICE

To share the same perception of reality, focusing on the topics initiated by the patient with severe dementia and a supporting attitude to what the patient tells, will hopefully give more episodes of lucidity in the patient. This approach in caring for patients with severe dementia might give more meaning and well-being to the conversational partners in daily care.

Cognitively Impaired Elderly and Their Adult Children

An aging parent’s development of a cognitive impairment requires significant changes in the lives of that individual and his or her family. Adult children may be required to assume caregiving responsibilities and may experience feelings of loss, as well as conflicting feelings of guilt, apprehension, anger, and resentment towards these responsibilities. This article explores the dynamic that underlies these sentiments and suggests strategies to maximize parent-child communication and facilitate the relationship between cognitively impaired elderly adults and their adult children.

Effectiveness of communication strategies used by caregivers of persons with Alzheimer's disease during activities of daily living

Communication difficulties between individuals with Alzheimer's disease (AD) and their caregivers are commonly reported. Caregivers carry the burden of managing breakdowns in communication because people with AD are often unable to modify their communicative behavior. To assist caregivers in this endeavor, clinicians and caregiving professionals have offered a variety of strategies aimed at accommodating the individual's declining abilities. Many of these strategies are intuitively appealing, but they lack empirical support. This study investigated the effectiveness of 10 frequently recommended communication strategies when employed by family caregivers of persons with AD. In particular, we assessed (a) which strategies family caregivers report using and with what degree of success, (b) which of these strategies are used by caregivers in actual interactions with their spouses, and (c) which strategies contribute to improved communication. The study included a self-report questionnaire and wireless audio-recorded interactions between 18 persons with AD and their spousal caregivers during activities of daily living. The findings validate the effectiveness of certain communication strategies (e.g., simple sentences) but not others (e.g., slow speech). The results should be of interest to both family members and professionals who want to enhance communication and the quality of their interactions with persons with Alzheimer's disease.

Discourse comprehension test performance of elders with dementia of the Alzheimer type

Spoken language comprehension, including comprehension for inferential material in narrative discourse, is diminished in dementia of the Alzheimer type (DAT). There are, however, no empirical data concerning comprehension by adults with DAT of main ideas versus details in narratives. Evidence from other groups with and without brain damage has shown that comprehension for main ideas is relatively better than for details and that comprehension for stated material is relatively better than comprehension for inferential material. Participants in the present investigation were 24 older adults, 8 with early-stage DAT (EDAT), 8 with middle-stage DAT (MDAT), and 8 with no brain damage (NBD). Selected narratives and associated sets of yes-no questions from the Discourse Comprehension Test (DCT) (Brookshire and Nicholas, 1993) were presented on videotape. Participants with EDAT and MDAT had significantly poorer overall comprehension of DCT narratives than did those in the NBD group (p < .0001), but they did not differ significantly from each other. Responses to DCT narratives by participants in the NBD, EDAT, and MDAT groups followed the same pattern of relatively better comprehension for main ideas than for details and relatively better comprehension for stated than for implied information. Working memory and episodic memory were shown to be significantly associated with DCT overall scores. Together, these findings suggest that although overall narrative comprehension is diminished in those with DAT, individuals appear to retain a mental representation for narratives that facilitates better comprehension of main ideas than of details as well as better comprehension of stated information than of implied information. This interpretation is consistent with schema-based accounts of narrative comprehension.

Recommended and reported use of communication strategies in Alzheimer caregiving

Individuals with Alzheimer disease experience cognitive and behavioral impairments that affect their ability to communicate. In an effort to compensate for these declines, a number of communication strategies have been recommended in the literature for Alzheimer disease caregivers. These include recommendations for caregivers to modify their language behavior and/or the context of communication. The purpose of this study was to (1) review the Alzheimer disease caregiving literature and identify communication strategies commonly recommended for family caregivers and (2) determine how often caregivers report using these strategies and how effective they feel each is in facilitating communication. A review of the literature identified 10 recurring communication strategies. A questionnaire was constructed that asked caregivers to report on the use and efficacy of these 10 strategies. Twenty family (spouse) caregivers of persons diagnosed with Alzheimer disease completed the questionnaire. The results show that caregivers perceived using the 10 strategies, although the strategies appearing most frequently in the literature were not necessarily the ones used most often by caregivers. A positive correlation was observed between caregivers' perceived use of strategies and their effectiveness. Use and efficacy of a strategy did not significantly vary as a function of dementia severity or the gender of the caregiver. The findings provide evidence that caregivers are aware of their communication behavior and modify it in ways that they think improve communication with their spouse.

Effects of caregiver communication on the outcomes of requests in spouses with dementia of the Alzheimer type

Three clinical and three matched nonclinical couples were studied for the effectiveness of their discourse in eliciting outcomes to requests made. Caregivers in the clinical couples were less likely to achieve successful outcomes than dominant communicators in the nonclinical couples. In studying the context for the requests, differences could not be attributed to the degree of concreteness of reference that was used by caregivers of spouses with Dementia of the Alzheimer type. More abstract and less abstract references were equally likely to be responded to by two of the three clinical couples. Differences in the styles of communication by the caregivers contributed to outcomes and reflected a self-reported degree of strain or comfort in the couples' relationships. Suggested is a method of study of outcomes that could be used in clinical assessment and intervention for nonresponsiveness and noncompliance with dementia patients.

Application of the correct information unit analysis to the naturally occurring conversation of a person with aphasia

The Correct Information Unit (CIU) analysis for measuring the communicative informativeness and efficiency of connected speech (Nicholas & Brookshire, 1993) was applied to the naturally occurring conversation of a person with moderate aphasia. Results indicated that, in this instance, reliable CIU measures could not be obtained. Intrarater reliability for CIU and %CIU was low, reaching only 72%, and interrater reliability was never greater than 63%. However, reliability of word counts was good. Post hoc analysis of rater disagreements in application of the CIU analysis revealed that the majority (72%) resulted from insufficiencies in the scoring rules that were originally designed to measure single speaker connected discourse. Two descriptive categories of disagreements were identified: interpretations of informativeness and absence of rules. The remaining 28% of disagreements were attributable to human error in the application of scoring rules. Comparison of findings with previous research and implications for future research are discussed.

Conversational discourse analysis as a method for evaluating progress in aphasia: a case report

The gains made by a woman with Broca's aphasia as documented by traditional measures were paralleled by changes in conversation, including increased verbal output and efficiency, and changes in conversation repair patterns. Her conversational partner decreased her verbal output, as predicted. The progress documented with conversational discourse analysis was not observable from other test measures. Clinical and theoretical implications are discussed.

Joint productions as a conversational strategy in aphasia

To address the longstanding question of the conversational ability of persons with aphasia, this study investigated the spontaneous occurrence of a specific type of conversational collaboration, joint production, that is known to occur in the conversation of ordinary speakers. A person with aphasia and his wife videorecorded eight of their naturally occurring conversations. These conversations were analysed and three types of joint productions were identified: word search, turn completion and appendor production. Additional sequential analysis revealed the linguistic, paralinguistic and contextual resources available to the interactants in designing their joint production. Results showed that, despite the presence of aphasia, this couple was able to successfully employ joint production as an interactive technique leading to conversational success. Implications of this study are discussed relative to the understanding of communicative ability of persons with aphasia and how aphasia is diagnostically and therapeutically approached.

Analysis of conversational topic shifts: a multiple case study

Investigation into the natural conversational discourse of patients with Dementia of the Alzheimer Type has received minimal attention, in part due to the inherent methodological problems. There are no satisfactory theoretical models of conversation; existing global checklists give minimal information on meaning relationships and analysis of conversation does not lend itself to group studies. The present study offered an initial example of how meaning relationships, expressed through topic shifting behavior, can be described in DAT and normal elderly subjects in natural conversational discourse. Categorization of topic units was done in an attempt to describe general phenomena, type of shift, reason for shift, and contextual relationship. Although very little differences were visually observed in the general categories, some convergence of data were observed in other topic shift categories. Discussion of the results in relation to a discourse processing model is presented.