The scope of using pragmatic language tests for early detection of dementia: A systematic review of investigations using figurative language

INTRODUCTION

Dementia cases are expected to rise to 81.1 million in 2040. Efforts are underway to develop diagnostic methods to facilitate early detection of the disease. Herein we review research findings focusing on pragmatic dysfunction in patients with dementia and evaluate the usefulness of assessing dementia and its progress with a battery of tests assessing figurative language skills.

METHODS

A total of 74,778 article titles were identified from EMBASE, PubMed, and Google Scholar databases. After systematic screening, 51 journal articles were selected for the final review.

RESULT

The review suggests that impaired figurative language might be a marker for early cognitive decline. Different forms of figurative language may be impaired at different stages of the disease and in different types of dementia involving different neuropathologies.

CONCLUSION

The use of pragmatic tests in combination with the existing diagnostic protocols might increase the probability of early diagnosis. HIGHLIGHTS Pragmatic impairment could be a marker of early cognitive impairment. Figurative language-an important pragmatic aspect-is disrupted in mild cognitive impairment (MCI) and early Alzheimer's disease (AD). Figurative language impairment might precede literal language impairment. Pragmatic tests could be more sensitive than standard neuropsychological tests. Inclusion of pragmatic tests in diagnostic guidelines might bolster early detection.

Anything Goes? Analyzing Varied Understandings of Assent

Assent to medical research or treatment may be an intuitively attractive way to address the area between incapacity and capacity that might otherwise be subject to a best interests assessment. Assent has become a widely disseminated concept in law, research, and clinical ethics, but little conceptual work on assent has so far occurred. An exploration of use of assent in treatment and research in children and people with dementia suggests that at least five claims are made on behalf of assent. Since at least some of these may lead to tensions with others, assent requires firmer conceptual underpinning. Whether assent remains primarily a local approach to research in children in the United States, where it appears to fit with legal background conditions, or develops its promise to overturn the dominant, binary, approach to (in)capacity will depend on the strength of future philosophical work to improve the theoretical foundations to assent.

Avoiding repair, maintaining face: Responding to hard-to-interpret talk from people living with dementia in the acute hospital

People living with dementia (PLWD) are almost always admitted to the acute hospital for reasons unrelated to their dementia, finding themselves in the unfamiliar environment of a Health Care of Older Persons acute ward. The effect of this environment creates a challenge not just for a PLWD themselves, but also for the staff who care for them. Concerns have been raised by both policy makers and staff about the quality of communication between hospital staff and PLWD. Using conversation analysis, we examined 41 video recordings of healthcare professional (HCP)/PLWD interactions collected across three acute inpatient wards in a large teaching hospital in the UK. In this paper, we focus our analysis on hard-to-interpret talk (talk where there are problems in hearing, speaking and/or understanding), and the ways in which healthcare professionals respond to this. Repair of hard- to- interpret talk is common in ordinary interaction, but we find that HCPs in this setting use a range of approaches to avoid direct repair. These approaches are: the use of non-committal responses and continuers such as 'yeah' or nods; the use of repetitions or partial repetitions; responding to the emotional tone displayed in the PLWD's utterance; closing the current topic and shifting to the next; and treating the PLWD's talk as related to the task at hand. We suggest that the use of these approaches may be one way in which HCPs manage respecting the personhood of the PLWD, by preserving face and enabling a continuation of an interaction in which the PLWD can take an active part. Our paper provides an empirical demonstration of the high level of interactional skill involved in dementia care work. It also illustrates how these skills can be described and specified, and hence incorporated into the recommendations and tips that are produced for communication with PLWD.

Facilitation of positive social interaction through visual art in dementia: a case study using video-analysis

The aims of this exploratory study were: to investigate the process of visual art appreciation in a person with dementia, in real time; and to test the feasibility of using video-analysis as a method to explore this process by and with a person who has minimal verbal expression. Gallery personnel guided a woman with severe dementia around an exhibition. Audio-visual recordings of the interactions were analysed. Patterns were identified, and interpreted in the light of conversation analysis theory and research. Evidence was found of turn-taking vocalisations on the part of the research participant. Her participation in a dialogical process was facilitated by the skilled and empathic gallery personnel in ways that the analysis makes clear. We argue that this supports the inference that successful communicative acts took place, contrary to expectations in the light of the participant's level of disability. We demonstrate in this paper how a woman with minimal speech due to dementia was enabled to engage with visual art through the facilitation of an expert guide, attuned to her needs. This is a novel example of a person-centred approach, because it takes place outside the context of caring, which is the typical setting for examining person-centred ways of relating to individuals with dementia.

Communication in healthcare interactions in dementia: a systematic review of observational studies

BACKGROUND

Communication is affected by dementia, even in the early stages. Studies directly observing how patients, companions and healthcare professionals communicate have not yet been reviewed.

METHODS

Eight databases were searched, and hand searches of relevant journals and grey literature were performed up to August 2014. Two authors reviewed abstracts independently and collectively reviewed for agreement of inclusion. Findings were narratively synthesized.

RESULTS

23 studies were identified observing: diagnostic, follow up, day center, primary care and research consent interactions. Companions were present in 14 studies. Three themes emerged: emotional impact of diagnosis, level of patient involvement and participant strategies to save face and cope with cognitive impairment. Eight studies observed diagnostic disclosure describing emotional reactions, with professionals using mitigating language and rarely checking patient understanding. Studies reported varying patient involvement, showing marginalization in primary care but not in assessments or diagnostic feedback. Patients used humor and metaphor to compensate for difficulties retrieving information and responding appropriately, suggesting preserved awareness of the pragmatics of interaction. Companion roles fluctuated between patient advocate and professional informant. Professionals encountered challenges adapting to heterogeneous patient groups with varying capabilities and needs.

CONCLUSIONS

Patient-companion-professional communication in dementia care raises various ethical questions: how to strike a balance between different communicative needs of patients and companions; clarity versus sensitivity in delivery of the diagnosis; and whether to minimize or expose interactional difficulties and misunderstanding to enrich patient understanding and involvement. Healthcare professionals need guidance in delivering a diagnosis and strategies to optimize patient and companion participation.