Journalof Speech and Hearing Research, Volume 34, 831-844, August 1991

Communication Treatment for

Adults With Dementia

Michelle S. Bourgeois ______

University of Pittsburgh

Intervention studies reporting improvements in communication skills inaging adults presumed

to have dementia were identified and reviewed. Whereas the speech-language pathology
journals have published only articles on the diagnosis and identification of communication
deficits in adults with dementia, over 100 articles on treatments effecting changes in communi-
cative deficiencies were found in psychology, social work, nursing, and gerontology journals.
Much evidence supports the potential for positive outcomes from communication treatment with
this population. Various design and methodological flaws, however, limit the extent to which
these interventions should be applied without further research. Issues of ethics and social
validity are discussed, and treatment and research needs are outlined.
KEY WORDS: dementia, communication treatment, adult language disorders

Increasing numbers of elderly adults are diagnosed as suffering from dementia.

The current Alzheimer's disease (AD) prevalence rate is estimated to be as high as
10.3% of individuals over 65 years of age (Evans et al., 1989). Individuals with
dementia exhibit a wide variety of problem behaviors, many of which may be alterable
with appropriate techniques. For example, researchers have demonstrated some
success in managing delusions, hallucinations, agitation, hostility, and emotional
lability using drug treatments (Antoine, Holland, & Scruggs, 1986; Brinkman &
Gershon, 1983; Lovett et al., 1987).1 Family counseling, another common form of
therapy, usually addresses legal, bereavement, and institutional placement issues
(e.g., Ferris, Steinberg, Shulman, Kahn, & Reisberg, 1987; Kahan, Kemp, Staples, &
Brummel-Smith, 1985). One conspicuous void in the treatment literature concerns
investigations of ways to maintain communicative functioning in aging adults with
chronic diffuse and degenerative neurologic disease.
Communication symptoms in this population are many and varied. Word-finding
problems become apparent when nonspecific terms replace substantive nouns,
resulting in vague and empty speech (Nicholas, Obler, Albert, & Helm-Estabrooks,
1985). Verbal perseverations are frequent, particularly the repetition of ideas.
Pragmatic skills, such as topic maintenance and turn-taking, become disordered.
Other communication problems include diminished vocabulary and reading compre-
hension, faulty linguistic reasoning, changes in word association patterns, and
disordered oral and written discourse. By the late stages of the disease, mutism,
echolalia, and bizarre nonsensical utterances may be the only product of communi-
cative attempts.
Many of these communication deficits are likely the result of memory deficits.
Memory dysfunction is frequently identified as the earliest symptom of AD (Swihart &
Pirozzolo, 1988), and its devastating progressive decline has been well charted (see

'Paradoxically, some of these same psychotropic and anticholinergic drugs have been shown to impair
memory and learning skills (Davis &Yesavage, 1979; Reus, Weingartner, & Post, 1979).

© 1991, American Speech-Language-Hearing Association 831 0022-4685/913404-0831$0 1.0010

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 832 Journal of Speech and Heanng Research 34 81-844 August 1991

Bayles & Kasniak, 1987, for review). Although access to both applying similar technologies to the dementing elderly
the episodic (temporal record of unique episodes and events (Hodge, 1984).
in the person's life) and semantic (knowledge of words and The definition of communication for this review was com-
concepts) aspects of long-term memory is affected (Bayles & prehensive and included any appropriate or inappropriate
Kasniak, 1987; Corkin, 1982, Miller, 1981, Weingartner et al., verbalizations, social interactions involving both verbal and
1981), some research suggests the relative preservation of nonverbal communication, and any verbal excesses, such as
procedural memory in dementia patients (Eslinger & Dama- echolalia, screaming, and bizarre/confused language. Inter-
sio, 1985; Grober, 1986; Martone, Butters, Payne, Becker, & ventions that involved speaking or processing written stimuli,
Sax, 1984). Procedural memory includes the memory traces even if the major dependent variables were not communica-
laid down during skill acquisition, perceptual learning, and tion related (e.g., attendance at activities, depression, self-
classical conditioning (Squire, 1987). In contrast to episodic
esteem), were reviewed. Much of the literature reflects
and semantic memory information, procedural memories are
attempts to address problems that institutional staff com-
not accessible as specific facts, data, or events, but as rules
or procedures. The distinction between procedural and epi- monly observe (e.g., that elderly demented patients withdraw
sodic/semantic memories has also been cast as the differ- socially, spend many hours alone, and become depressed).
ence between "knowing how" and "knowing that." Hence, many interventions have been designed to foster
Distinctions such as these can be subsumed under a social interaction and participation in group activities with the
continuum reflecting the relative mental effort required to goal of improving the quality of life; improved communication
process a given stimulus or situation (see Mandler, 1989). is often reported as an unexpected, anecdotal effect. Unfor-
When cognitive processing requires conscious effort, such as tunately, most of the studies are largely descriptive, do not
intentional decision making, active memory search, or orga- directly measure the communication skills reported, consist
nizing information, dementia patients are particularly im- of case histories, and are evaluated subjectively. Neverthe-
paired (Davis & Mumford, 1984; Miller, 1975). However, less, the amount of indirect evidence of improved communi-
relatively automatic processes, which result from much prac- cation resulting from a variety of interventions is reason for
tice and experience (Hasher & Zacks, 1979), are generally optimism. This review will synthesize this divergent literature
better preserved, at least in the early to middle stages of the and identify those treatment strategies that appear promising
disease (e.g., Jorm, 1986; Nebes, Boiler, & Holland, 1986; either on empirical or theoretical grounds.
Nebes, Martin, & Horn, 1984; Weingartner et al., 1981). This
framework suggests that effective interventions may be pos-
sible with dementia patients to the extent that they capitalize
Methodological Note: Selection of Articles
on relatively automatic processes.
Diagnosis of AD can mean living with deteriorating illness Intervention studies involving patients with communication
for 3-20 years. Therefore, it behooves speech-language
disorders associated with chronic, progressive dementias
pathologists to develop treatment programs that ameliorate
were reviewed. An exhaustive search was conducted for
communication deficits in clinically significant ways, even if
nonmedical interventions for the medically and surgically
the effects of therapy may not be long-lasting. Within the past
20 years, the journals of the American Speech-Language- untreatable dementias, such as Alzheimer's disease (also
Hearing Association have not published a single treatment referred to as senile dementia, senile brain disease, organic
study in this area. The description and differential diagnosis brain syndrome), idiopathic Parkinson's disease, Hunting-
of disease-specific language and cognitive disabilities have ton's disease, Creutzfeldt-Jakob disease, Pick's disease,
been the major focus of research in this area (Bayles & Korsakoff's disease, progressive supranuclear palsy, pro-
Boone, 1982; Bayles, Boone, Tomoeda, Slauson, & Kasz- gressive subcortical gliosis, and multi-infarct dementia
niak, 1989; Bayles & Tomoeda, 1990; Bollinger, 1974; Disi- (Foley, 1972). It was difficult to exclude studies on the basis
moni, Darley, & Aronson, 1977; Fromm & Holland, 1989; of diagnosis only because descriptions of subjects' diag-
Halpern, Darley, & Brown, 1973; Kempler, Curtiss, & Jack- noses, and cognitive, intellectual, and behavioral functioning
son, 1987; Lubinski, Morrison, & Rigrodsky, 1981; Madison were inadequate in many studies. As Gilewski (1986) points
et al., 1977; Ripich & Terrell, 1988). out in his review of group therapy with cognitively impaired
This review identifies promising areas of clinical investiga- older adults, the diagnostic descriptors for cognitive impair-
tion from other disciplines, such as psychology, social work, ment have changed with increased sophistication of diagnos-
and nursing, relevant to the development of communication tic techniques. The lack of differential diagnostic procedures
interventions for patients with memory impairment due to in the past resulted in the undifferentiated care in institutional
dementia. Behavioral psychologists overwhelmingly have settings of individuals with diagnoses as varied as senile
taken the initiative in exploring treatment options for patients psychosis, chronic brain syndrome, delirium/confusion, and
with cognitive impairments, including communication deficits schizophrenia. The subjects targeted for treatment in the
(Burgio & Burgio, 1986; Hoyer, 1973; Hoyer, Mishara, & studies reviewed were mostly institutionalized and repre-
Riebel, 1975; Hussian & Davis, 1985; LaBouvie-Vief, Hoyer, sented a wide variety of etiologies. Studies were excluded
Baltes, & Baltes, 1974; McEvoy, 1989; Patterson et al., 1982; from review when subjects were described as having focal
Williamson & Ascione, 1983). Successful intervention studies brain injury, specifically the aphasias and right hemisphere
with other difficult-to-teach populations, such as persons with damage. Studies addressing the language problems of el-
mental retardation and autism, have provided impetus for derly patients with mental retardation were also excluded.

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 Bourgeois: Communication Treatment for Dementia 833

Intervention Literature: What Do We Know? cognitively impaired elderly nursing home residents had
access to coffee and cookies during activity times; they had
Over 100 articles describing interventions with measurable anecdotal evidence that improvements were maintained 4
or anecdotal effects on the communication of persons with months after treatment ended. In a more detailed analysis of
dementia were identified. The first part of this review consid- the content of verbal behaviors exhibited by 30 nursing home
ers studies that focus on changing the patient's environment, residents during a social hour with refreshments, Cartensen
the stimulus conditions to which the patient is asked to and Erickson (1986) found positive changes as a function of
respond, and the consequences patients receive as a result the presence of refreshments. Yet, ineffective communicative
of responding appropriately. Multicomponent packages for behaviors also were observed to increase (incoherent or
treating specific skills are then discussed. Finally, group nonsensical utterances, or no response) and some appropri-
therapy interventions are analyzed. In each section, method- ate communicative behaviors decreased (questions, state-
ologic limitations and recommendations for improvement are ments of fact or opinion).
also presented. Although promising treatment approaches One major problem with this approach to treatment is that
are identified, the reader is advised to interpret reported researchers have not established reliable relationships be-
results with caution. With the exception of the behavior tween specific environmental changes and changes in indi-
analytic investigations, much of this literature is descriptive in viduals. These treatments have been applied too globally;
nature and many of the experimental studies lack method- they are given to everyone in the same manner, regardless of
ological rigor. diagnosis or severity. Researchers need to identify specific
communication deficits in a well-defined patient population,
develop a reasonable measurement procedure for tracking
Changing the Communication Environment the communication deficit before and throughout treatment,
The setting for communication affects both the quality and and plan a replicable and reliably implemented treatment to
quantity of communication. Institutional, long-term care set- address the problem.
tings are typically devoid of the comforting, homelike atmo- In addition, there are no qualitative expectations for patient
spheres that many clinicians assume foster communication. performance in these environmental manipulation studies. If
Similarly, the isolation of homebound patients also creates a subject talks, smiles, or appears to be in a positive mood
an undesirable setting for communication. Changes in a when interacting with a conversational partner, then the
variety of communication skills have resulted from simple "intervention" is successful. Criteria for evaluating interven-
environmental modifications, including rearranging furniture tion efficacy must be more stringent and more ecologically
(e.g., Melin & Gotestam, 1981), adding plants, pictures, and valid. For example, amount of conversation is too general as
other homey decorations (e.g., Gottesman, 1965), providing a dependent measure if increases can reflect confabulatory
conversational partners (peers, children, pets) (e.g., Corson utterances as well as factual statements. Researchers can
& Corson, 1978), offering group activities (e.g., Blackman, avoid promoting inappropriate and ineffectual communication
Howe, & Pinkston, 1976), and combining these factors (often (e.g., Carstensen & Erickson, 1986) by designing interven-
referred to as milieu therapy; e.g., Loew & Silverstone, tions that are likely to change specific, qualitatively defined
1971).2 Environmental manipulations appear to increase behaviors in the desired direction, but are flexible enough to
opportunities for communication, or to provide more topics be altered when optimal outcomes are not obtained.
for conversation. They are low-cost, minimally intrusive, and
common sense ways to promote a desirable, comfortable
situation for communication. Analysis of Controlling Stimulus Conditions
In general, lack of clearly defined dependent variables,
poor subject descriptions, and inadequate outcome mea- A second approach to treatment can be conceptualized as
sures restrict the interpretation of results of many of these attempts to analyze memory and skill deficit problems of the
studies. Several carefully executed experimental studies, dementing elderly person as problems in stimulus control.
however, validate the importance of attending to environ- That is, antecedent stimuli in the everyday environment no
mental factors in designing treatment programs for demented longer have the usual effect on a patient. Patients may not
patients. For example, Blackman et al. (1976), using a group attend to relevant cues in social situations or they may be
ABAB withdrawal design with 30 elderly institutionalized distracted by irrelevant cues. Theoretically, if relevant stimuli
(further undescribed) women, demonstrated improvements can somehow be enhanced, patients might be better able to
in prosocial (speaking, listening, touching), antisocial (verbal recognize them and use them appropriately.
harassment, threats, physical violence), and nonsocial be- Stimulus enhancement studies have developed along two
haviors (sitting, remaining silent, and talking to self) when major premises: Patients can be retrained to attend to and
coffee and juice were available during a scheduled activity recall relevant stimuli using internal, self-monitored memory
period. Quattrochi-Tubin and Jason (1980) attained similar enhancing strategies, or the stimuli themselves can be
increases in the frequency of social interactions (defined as altered (enlarged, brightly colored, highlighted, or somehow
verbally conversing or nonverbal game-playing) when 56 made more obvious than the background environmental
stimuli) to help trigger associations stored in memory (e.g.,
external strategies). Normally aging adults have demon-
2
A comprehensive bibliography of environmental interventions with reported strated learning effects on recall tasks with a multitude of
effects on communication is available from the author upon request. internal memory strategies, including visual and verbal im-

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 834 Journal of Speech and Heanring Research 34 831-844 Augiust 991

agery and mnemonics, motor coding, mental retracing of particularly because many of them will develop sensory
events, and concentration and attention training (Wilson & impairments in the later stages of their disease.
Moffat, 1983; Yesavage, 1983, 1985; Yesavage, Rose, & Researchers have demonstrated that training patients to
Bower, 1983). Preliminary attempts to apply these tech- attend to enhanced environmental stimuli improves the ef-
niques with demented patients, however, have been disap- fectiveness of the stimuli. Hanley (1981) differentially modi-
pointing because extensive training efforts result in small fied residents' ward orientation by posting signs alone or by
gains. Additionally, recalling lists of words (Miller, 1975; Zarit, training the residents to attend to the posted signs; with
Zarit, & Reever, 1982) and recalling names/faces for longer training, residents learned room locations faster than with
intervals between training and testing sessions using imag- signs alone. Hanley and Lusty (1984) compared the relative
ery and mnemonic techniques (Hill, Evandovich, Sheikh, & effectiveness of memory aids (watch and diary) versus
Yesavage, 1987) may not be functional skills for the patient. memory aids plus training on an 84-year-old demented
patient's ability to answer personal orientation questions and
Although interesting from a theoretical standpoint, attempt-
remember appointments. This patient did not learn to use the
ing to teach internal memory strategies to patients with aids reliably until she had had 2 weeks of training. Thereafter,
dementia may have limited practical application (Mateer & the patient consulted her diary to remember personal infor-
Sohlberg, 1988). Internal, self-monitored strategies require mation and appointments when prompted by staff; without
conscious, effortful processing by the patient. Although the prompting, however, the patient could not maintain self-
mildly demented patient may demonstrate strategy learning initiated memory aid use.
for short-time periods in a laboratory setting, there is no Training to use an external memory aid should be viewed
evidence that this learning will generalize to everyday mem- differently from training an internal memory strategy; the
ory problems or will maintain as the patient becomes more former is always associated with the permanent physical
demented (Perlmutter, 1978). prompt-the memory aid-whereas the latter is supposed to
External memory aids are potentially more practical be- become part of the patient's internal self-monitored reper-
cause they provide recognition cues that restrict the range of toire. As a result, "training" to use a memory aid is actually
possible choices for responding. A wealth of external mem- reinforcing patients for interacting with stimuli in their envi-
ory aids have been suggested including notebooks, calen- ronment (e.g., whenever you see the sign, you read it;
dars, signs, and timers (Wilson & Moffat, 1983). Several whenever you touch your memory book, you open it and read
recently published guidebooks for the families of Alzheimer's it). Pairing external aids with familiar and spared skills, such
disease patients (Glickstein, 1988; Mace & Rabins, 1981; as turning pages and reading aloud, should maximize a
Ostuni & Santo Pietro, 1986; Rimmer, 1987; Sheridan, 1987; patient's opportunity for success because the spared skills
Tanner & Shaw, 1985) include specific suggestions for rely on automatic memory processes, and because the
providing "extra" contextual stimuli (signs, labels, color stimuli in the aids are relevant to a patient's everyday life.
codes, etc.), regrettably without much empirical basis. Nev- Prompts for everyday functional skills, in the form of
ertheless, in contrast to internal memory strategies, the use portable and personalized aids such as cue cards or memory
of external memory aids and contextual cues is encouraging. wallets, have also been investigated. Smith (1988) success-
The first experimental investigations of the effects of such fully decreased a patient's repetitious questioning, and the
contextual cues explored the usefulness of different sensory resulting arguments with his spouse, by having the spouse
stimuli for prompting appropriate responding. McClannahan hand the patient cue cards with appropriate responses to the
and Risley (1974) compared the relative effectiveness of questions. Similarly, Bourgeois (1990a) increased appropri-
three types of announcements (public address system an- ate statements of fact and decreased ambiguous, persever-
nouncements, amplified announcements at dining tables ative, and unintelligible utterances in the conversations of
during lunch, and large-print sign posted at entrance of dining demented patients using a communication/memory wallet
hall) for evoking nursing home residents' participation in a containing personally relevant sentences and pictures. This
social hour. All three prompting conditions were equally type of external memory aid has the potential to elicit durable
effective at increasing participation in the social hour when and longlasting effects because the improved skills are useful
compared with a no-prompting condition. The investigators to a patient in everyday life and recruit natural reinforcement
observed residents prompting each other verbally to attend from others. Also, external memory aids provide many op-
the social hour during announcement conditions, effectively portunities for a patient to use them daily because they can
increasing social interaction and conversation. There is also be tailored to meet changing needs, and they are tangible,
some evidence of the increased effectiveness of verbal permanent prompting mechanisms. Normally aging adults
prompts over other prompts (signs, loudspeaker, invitations) with no measurable memory impairments have benefited
for eliciting participation in group activities (Newkirk, Feld- from a variety of similar prompting systems, ranging from
man, Bickett, Gipson, & Lutzker 1976; Reitz, 1978). For appointment books and calendars to 7-day pill dispensers
example, McClannahan and Risley (1975) found that a visual (Ascione & Shimp, 1984). The self-prompting system most
prompt (simply making materials available) was not as effec- beneficial to a patient might be the one he or she used before
tive as verbal prompts by staff members to engage In developing dementia because it might already be part of a
activities (25% participation with visual and 74% participation repertoire of automatic skills.
with verbal prompts). These preliminary findings should Another stimulus control treatment approach that merits
motivate further exploration of the visual, acoustic, and tactile review because of its popularity in institutional settings is
characteristics of stimuli presented to dementia patients, Reality Orientation (RO) (Folsom, 1968). This program at-

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 Bourgeois: Commumcatlon Treatment for Dementia 835

tempts to improve cognitive and behavioral functioning of frequently stationary (i.e., posted on the wall of a room that
institutionalized patients through repeated verbal presenta- the patient may not be in when he needs to refer to it),
tion of orientation-related information, correction of confused transient (i.e., auditory information has no permanent prod-
speech and behavior, and encouragement of greater levels uct), or of insufficient auditory or visual intensity to be noticed
of behavioral independence. As RO has been implemented by elderly patients with known sensory deficits. Second, RO
and modified over the years, the overall objective remains to information is often overwhelmingly complex; it may include
maintain previously acquired skills by providing prompts and every daily activity for an entire month without enhancing the
cues, rather than to teach new skills. The prompts and cues current day's activities. Last, staff assume that patients will
are usually in the form of a standard set of orientation facts, attend to and understand posted information without staff
representing the date, location, next anticipated holiday, and assistance. Intuitively, a portable, permanent set of individu-
outside weather conditions, that are printed in large type and alized factual cues (wallet, cue cards, etc.) relevant to
posted in a common area. Training usually consists of important aspects of the patient's daily life, to which the
minimal daily exposure to these facts in a classroom format patient could refer whenever and wherever a memory lapse
(Barnes, 1974; Cornbleth & Cornbleth, 1979; Drummond, occurred, might have more potential for prompting desired
Kirchoff, & Scarbrough, 1978; Goldstein et al., 1982; Greene, communicative responses.
Timbury, Smith, & Gardiner, 1983; Hanley, McGuire, & Boyd, Finally, the salience of stimuli can be enhanced with
1981; Johnson, McLaren, & McPherson, 1981; Reeve & training, or routine and repetitive exposure (Hanley, 1981;
Ivison, 1985), as a 24-hour environment-wide treatment Hanley & Lusty, 1984). The assumption that external cues
(Zepelin, Wolfe, & Kleinplatz, 1981), or as a combined should work because they seem obviously magnified will
classroom plus 24-hour program (Citrin & Dixon, 1977; Harris lead to carefully labeled and visually enhanced environments
& Ivory, 1976). Reviews of RO evaluation studies are equiv- that patients may not notice. Treatment programs utilizing
ocal in their conclusions about its effectiveness, because it is enhanced stimuli need to include training and maintenance
difficult to compare studies with multiple methodological procedures to ensure that environmental cues become func-
variations, small patient groups of questionable homogene- tional for patients. For example, frequently pointing to en-
ity, and nonstandard outcome measures (Greene, 1984; larged print name tags and reading aloud the names may
Hanley, 1984; Powell-Proctor & Miller, 1982). Further, few help patients to remember familiar staff.
studies have measured the extent of the treatment's effec- In general, more systematic investigations are needed of
tiveness beyond the trained skill of answering orientation the relative effects of various external memory aids and
questions (Greene, 1984). contextual cues on well-described individuals exhibiting the
Single-subject studies of RO therapy have made more entire range of cognitive disability. In addition, we need to
progress in identifying relevant treatment variables (Greene, learn more about the relationship between specific stimuli of
Nicol, & Jamison, 1979; Hanley, 1981, 1986; Hanley & Lusty, varying complexity and patient behavior. For example, when
1984) and in remedying the methodological problems com- does the environment contain too many stimuli, resulting in
mon in this literature. Specifically, there is evidence that confused states for some patients, or too few stimuli, result-
attending to the quantity and quality of individuals' responses ing in withdrawal, apathy, depression, and loss of skills for
and providing appropriate reinforcement improves the post- others? Investigations of "reduced stimulation" nursing home
test scores of cognitively impaired residents on orientation units indicate that some AD patients show improved commu-
questions compared with control group residents who de- nication with family members and increased interpersonal
clined on the same measures (Hanley, McGuire, & Boyd, relationships with staff and other patients when the level of
1981; Woods, 1979). Nevertheless, prior reviews have over- stimulation is reduced to minimize reliance on memory
looked other factors that could make RO a more robust (Cleary, Clamon, Price, & Shullaw, 1988).
treatment. First, the choice of factual information used in RO
may have little functional use for patients. How often in daily
conversation does one discuss the next holiday or reflect on Changing the Consequences of Appropriate
what day, date, or year it is? Clinicians assume that patients Communication
need to be oriented in time, but unless temporal information
is associated with meaningful activities or events there may The effects of reinforcing consequences on behavior
be little justification for effort expended to get a patient to change have been documented in a variety of situations with
remember that today is Monday, March 10, 1990. Patients demented patients. Tangible reinforcers such as candy,
may benefit, however, from practicing that today is Monday cigarettes, and exchangeable tokens (Atthowe & Krasner,
and on Mondays we go to Bingo at 11 a.m. 1968; Ayllon & Azrin, 1965; Kazdin & Bootzin, 1972; Lee,
Second, the factual information of most immediate use to 1969; Mishara, 1971, 1978; Mueller & Atlas, 1972; Nelson &
patients may be inaccessible. For example, the daily activi- Cone, 1979), reportedly have increased conversational inter-
ties schedule, although posted on a wall in a common area action in group therapy (Mueller & Atlas, 1972), nondelu-
and printed in large type or verbally announced by staff sional answers to direct questions (Patterson & Teigen,
members, is not salient enough to cue appropriate atten- 1973), memory for orientation facts (Beck, 1982), and fre-
dance at activities. Also, patients may never learn the names quency and length of verbalizations (Hoyer, Kafer, Simpson,
of familiar staff in spite of name identification tags or occa- & Hoyer, 1974).
sional verbal references to staff by name. These external Other reinforcement techniques, such as differential rein-
cues fail for several reasons. First, the RO information is forcement, planned ignoring, and response feedback, have

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 836 Journal of Speech and Hearing Research 34 831-844 August 991

also been shown to be effective. Verbal initiations (MacDon- treatment packages incorporating all potentially beneficial
ald, 1978), verbal interactions, and correct responses to components from their respective theoretical approaches.
orientation questions (Hoyer et al., 1975) have increased On a large scale, RO, token economy, and milieu training
when staff conversed with or praised patients contingently. programs are adopted for environment-wide implementation
The reinforcement of incompatible, appropriate behaviors in institutional settings; changes in multiple problem behav-
effectively decreased the screaming behavior of 1 patient iors and skills deficits are targeted for all patients. At the other
(Baltes & Lascomb, 1975). Withholding reinforcement by end of the continuum, interpersonal and communication skills
ignoring bizarre verbalizations modified the behavior of a training packages incorporate many successful behavioral
patient who verbalized that "voices" told him not to wear training techniques to train smaller groups of patients a few
clothes (Mishara, Robertson, & Kastenbaum, 1973). Spayd specific skills (Berger & Rose, 1977; Lopez, Hoyer, Gold-
and Smyer (1988) decreased inappropriate and increased stein, Gershaw, & Sprafkin, 1980; McEvoy & Patterson,
appropriate verbalizations of a confused elderly man by 1986; Praderas & MacDonald, 1986).
training nursing home residents and staff to ignore his Evaluations of multicomponent treatment packages ad-
inappropriate verbalizations (verbally aggressive statements dress either the overall success of the entire program for the
and vulgarities) while paying attention to him when he made treated group, or the relative effects of different packages for
pleasant statements. Similarly, Carstensen and Fremouw comparable groups. Unfortunately, few studies report signif-
(1981) decreased paranoid verbalizations in an elderly icantly different outcomes when comparing treatments (Levy,
woman with this technique. Providing response-specific Derogatis, Gallagher, & Gatz, 1980). RO interventions are
feedback about the spoken orientation responses of de- more effective than no treatment groups or minimal interven-
mented patients increased correct responding; additionally, tion groups on skills specifically practiced (e.g., orientation
generalization to nontrained orientation items and improved questions). Generalization to other cognitive and behavioral
ratings of performance in occupational therapy were reported skills, however, is usually lacking (Brook, Degun, & Mather,
(Greene et al., 1979). 1975; Hanley et al., 1981; Harris & Ivory, 1976; Hart &
The use of reinforcement paradigms with demented indi- Fleming, 1985; Johnson et al., 1981; Zepelin et al., 1981).
viduals has provided many examples of positive outcome Token economy interventions produce more significant
and some generalized effects. This may be the result of changes on measures of social behavior and independence
specifying identifiable target behaviors and reinforcement than other treatment or nontreatment groups (milieu vs.
contingencies, applying treatments consistently and reliably, token economy-Greenberg, Scott, Pisa, & Friesen, 1975;
monitoring individuals' performance during training, and Mishara, 1978; Mishara et al., 1973; token economy vs. no
using behavioral observation outcome measures in addition treatment-Gripp & Magaro, 1971; Maley, Feldman, &
to questionnaires and rating scales, all hallmarks of the Ruskin, 1973; Shean & Zeidberg, 1971). These meager
behavior analytic approach. Additionally, the success of effects, however, may simply reflect the expectation that
reinforcement approaches may be because intervention is providing a structured program will result in more change
applied in the natural setting, can be applied by any trained than no treatment; qualitative changes have not been ad-
person, and usually involves a patient in positive activities dressed.
that can become self-reinforcing, such as conversations or Comparison studies of multicomponent treatments only
arts and crafts. Determining appropriate reinforcing contin- compound the problems inherent inthe evaluation of single-
gencies should be an ongoing, individualized task. Assuming treatment interventions. The relative gains of one treatment
that accurate performance alone will be intrinsically motivat- over another may be meaningless when the efficacy of
ing to a patient, however, may lead to treatment failure. individual approaches is not yet clear. This is exacerbated by
Cognitively impaired patients may not be able to sustain uncertainty about treatment fidelity when treatment is deliv-
self-monitoring activities without some external support inthe ered by multiple personnel without monitoring of the inde-
form of reinforcement. Further, this reinforcement may need pendent variables; by variability in subject performance,
to be continuously, rather than intermittently, available (Law- which is usually masked by grouping data across individuals
ton, 1980; Lindsley, 1964). and may contribute to weak treatment effects (Mishara,
Although consequating variables have been shown to be 1978); and by the use of nonstandard measurement and
potent and necessary, they may not be sufficient for maxi- rating forms completed by study participants, as opposed to
mizing outcomes. The overall management plan for an naive observers, to document treatment success (MacDon-
individual patient should utilize a combination of successful ald & Settin, 1978; Toseland & Rose, 1978). Further, when
strategies. The three approaches to intervention reviewed the effects of specific treatment components on individual
above demonstrate that attention to simple, low-cost, envi- patients are not monitored or not reported, it is difficult to
ronmental variables has the potential to affect the communi- generalize treatment expectations to other patients.
cative behavior of cognitively impaired elderly persons. Re- The complexity of treatment packages involving many
searchers have begun to study the potentially additive effects techniques, such as didactic instruction, modeling, roleplay,
of combining successful strategies in developing treatment feedback and reinforcement, transfer of training program-
programs. ming, memory aids, training frequency, and booster sessions
to review learned material, may be overkill. Patients may all
acquire trained skills regardless of systematic procedural
Multicomponent Treatment Packages variations (Lopez et al., 1980), or one training component
To maximize treatment gains, researchers have developed may stand out as particularly effective at increasing training

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 Bourgeois: Communication Treatment for Dementia 837

effects (McEvoy & Patterson, 1986). Component analyses of and Neuschatz (1985) noted that "when dialogue is focused
treatment packages are still needed to tease out the relative on a specific topic, it is amazing how even a patient who is
effects of specific teaching procedures. It seems obvious that severely impaired mentally and who rarely makes sense in
a treatment including all of the known successful behavior independent conversation is able to organize thoughts co-
change strategies would be very potent. Nevertheless, to herently and make appropriate comment," and that "ad-
maximize efficiency and cost effectiveness it would be helpful dressing an individual directly with a question is best for
to know which components are most important and which eliciting maximum participation" (p. 71). An individual's group
could be eliminated without seriously compromising the therapy treatment plan could be modified to include the use
results. of topic prompts or direct questions and a measurement
system to gauge their effectiveness.
In summary, the descriptions of group therapy interven-
Group Therapy Interventions tions often are suggestive of overall positive effects, particu-
larly for verbal and social interaction. Much research is still
Many interventions have utilized group therapy as the needed to evaluate the effectiveness of specific treatment
vehicle for modifying the behavior of cognitively impaired strategies. Whereas the time/cost benefits of group therapy
adults. As Lubinski (1978) reflected, the group therapy seem obvious, there may be other positive results of group-
process is "a means to establish an interpersonal situation in ing patients for communication therapy, including opportuni-
which meaningful, motivating, and reinforcing communica- ties for social interaction and natural reinforcement of com-
tion can occur" (p. 242). Common goals are to stimulate municative attempts. Group therapy programs that provide
verbalizations, to increase interactions among group mem- descriptions of replicable treatment procedures for operation-
bers, and to help group members renew their independence ally defined target behaviors, and that monitor individuals'
(Feil, 1967). Group therapy approaches include remotivation performance using reliable measurement systems are re-
therapy (Bowers, Anderson, Blomeier, & Pelz, 1967), sen- quired to determine the effectiveness of treatment in groups.
sory training (Rosen, 1982), resocialization therapy (Brudno
& Seltzer, 1968; Siegel & Lasker, 1978), reminiscence ther-
apy (Coleman, 1986; Cook, 1984; Hughston & Merriam, Caregivers as Communication Partners with
1982; Lesser, Lazarus, Frankel, & Havasy, 1981; Merriam, Dementia Patients
1980; Norris & Abu El Eileh, 1982), and life review therapy
(Butler, 1963; Kiernat, 1979; Lewis & Butler, 1974). Many The communication deficits associated with dementing
psychologists use these "verbal" therapies to effect changes illnesses affect not only the patient, but also the patient's
in other dependent measures, such as depression, anxiety, caregivers. The caregiver, most often the spouse, is usually
self-esteem, and somatic complaints (Ingersoll & Silverman, the first person to recognize subtle changes in the patient
1978; Steuer et al., 1984) without measuring either the due to cognitive impairment. Before receiving a confirmed
quality or quantity of patient verbalization. Yet there is no diagnosis of a dementing illness, the caregiver may misinter-
paucity of anecdotal reports of improved verbal and social pret the patient's frequent repetitive requests, memory
interaction in therapy groups (e.g., Brudno & Seltzer, 1968; lapses, and unreasonable demands and arguments as de-
Burnside, 1971; Rosen, 1982; Shere, 1964; Welden & liberate attempts to make the caregiver miserable. Once
Yesavage, 1982). diagnosed, the patient often becomes the focus of well-
The near-unanimous claims of success using group ther- intentioned, but misguided, attempts to help overcome mem-
apy with cognitively impaired older adults are tempered by ory deficits. Excessive demands to remember specific facts
methodological shortcomings in these studies (Burnside, and to practice self-help skills, expropriation of the patient's
1970; Gilewski, 1986). The positive results reported are hard routine household chores, and limitations on social activities
to generalize because patients with diverse and unclear quickly result in the caregiver feeling overwhelming stress
diagnostic etiologies are often grouped together for treat- and burden, and in the patient feeling demeaned, guilty about
ment, no two therapies are alike, and clinicians rarely utilize memory lapses, and hopeless (Barnes, Raskind, Scott, &
adequate outcome measures. Further, a group facilitator's Murphy, 1981; George & Gwyther, 1986; Zarit, Reever, &
clinical skills, theoretical approach, and personality are often Bach-Peterson, 1980). Early intervention with the caregiver
important, but unmeasured, independent variables. Compar- is crucial; education about the nature and course of the
isons of individual programs are therefore difficult; empirical disease, training about appropriate approaches to the pa-
evaluations of these interventions are nonexistent. Neverthe- tient's problem behaviors, and support group participation is
less, these studies do report changes in some dependent recommended (Greene & Monahan, 1989; Zarit & Zarit,
variables such as depression and anxiety for some patients, 1982).
improvements in patient and staff morale, and some improve- In the middle stages of dementia, the caregiver is often
ments in patients' cognitive and behavioral functioning. devastated by the patient's deteriorating skills and tired of
Speech-language pathologists are uniquely qualified to trying to cope with the increasing number and frequency of
assist professionals from other disciplines in improving the problems. Continued attempts to . communicate with the
quality of group therapies dependent on the verbal contribu- patient are seen as futile. Caregivers may become resigned
tions of participants. For example, they can translate com- to the loss of communicative interaction with the patient and
munication-related observations of group therapy effects into focus their energies on patient physical care and other
measurable treatment procedures and outcomes. Shoham problem behaviors, such as incontinence and wandering

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 838 Journal of Speech and Hearing Research 34 831-844 August 991

(Haley, Levine, Brown, Berry, & Hughes, 1987). Caregivers alter daily life, and that recruit naturally occurring reinforcers
need specific skill-based training to learn to shift their role in the environment. These skills will increase the likelihood of
from that of equal participant in communicative exchanges to maintenance and generalization to other behaviors or set-
that of facilitator of patient communicative attempts. tings. Treatment procedures should exploit a patient's re-
The utilization of caregivers (family or staff) as intervention maining abilities (e.g., desire to converse, reading aloud,
agents and as deliverers of natural consequences for appro- page turning) and seek to maintain these skills. Finally, goals
priate behaviors would appear to have multiple benefits for need to be selected to match the constraints and the advan-
patients, caregivers, and therapists. Patients may receive tages of the environment, in terms of communication de-
more opportunities to practice communication skills when the mands (e.g., number of settings and partners), expectations
person with whom they spend the most time serves as for communication use and how well those are met, and
"trainer." There may be more long-lasting and potent effects consequences of both appropriate and inadequate commu-
of this "therapy" when it is conducted in the patient's daily nication behavior (Stremel-Campbell & Campbell, 1985).
environment by the people who are most invested in the Traditional language assessment batteries may provide
patient maintaining appropriate communication. The litera- valuable information about the underlying skill deficits that
ture provides many examples of successful interventions patients exhibit (e.g., confrontation naming, recent memory,
targeting the behavior of caregivers, including nurses, ward comprehension) (Bayles & Kaszniak, 1987), but communica-
staff, spouses, and family members. Caregivers have been tion intervention goals need to be selected specifically to
taught an impressive array of skills that have been effective in address problems a patient encounters in his or her environ-
providing reinforcing and stimulating communicative environ- ment. Those who have trained traditional language or cog-
ments for patients. For example, caregivers learned to in- nitive skills such as match-to-sample tasks, reading tasks, or
crease the frequency of their task-related questions to pa- digit and word recall tasks with AD patients do not report
tients (Linsk, Howe, & Pinkston, 1975), to increase prompts generalization from trained tasks (e.g., improved digit recall)
to residents to participate in activities (Reitz, 1978), to to improved daily living behavior (Beck, Heacock, Mercer,
improve their communicative interactions with patients Thatcher, & Sparkman, 1988). Conversely, those who have
(Linsk, Miller, Pflam, & Ortigara-Vicik, 1986), to manage trained conversation skills have reported not only training
communication breakdowns (Shulman & Mandel, 1988), to effects but also generalization and maintenance of the
increase positive patient verbalizations (Green, Linsk, & trained behavior (Bourgeois, 1990a; Lopez et al., 1980;
Pinkston, 1986; Pinkston & Linsk, 1984) and to prompt Praderas & MacDonald, 1986).
patient problem-solving strategies (Cavanaugh et al., 1989).
Training, monitoring, and providing feedback for caregivers is
difficult and costly, but the benefits to caregivers from the Planning and Modifying Treatment as Dementia
positive changes they are empowered to make in the patient Progresses
(Bandura, 1977; Linsk et al., 1975) should make these Adapting treatment over time as the patient deteriorates is
expenditures worthwhile. Professionals can intervene more
especially important with this population. What works for a
effectively and with more patients when caregivers assist
patient in the early stages of dementia may need to be
with the daily treatment routine. altered to meet the patient's changing behavioral states,
increased memory loss, decreased attention span, and even-
Providing Communication Treatment: Where tual sensory deficits. In the early stages of dementia, a
Do We Go From Here? patient may be acutely aware of cognitive impairment, par-
ticularly memory deficits. Patients often request assistance in
The number and diversity of successful treatments affect- dealing with their memory failures, expressing eagerness to
ing the communication skills of adults with dementia is try any memory enhancing regime advertised in the popular
encouraging, but several issues need to be resolved before press. Withdrawal trom social situations, uncharacteristic
interventions with this population can proceed effectively and arguments, and vehement denial of cognitive changes are
ethically. These include the choice of treatment targets, the frequently symptoms of fear and anxiety regarding obvious
modification of treatment procedures and goals as dementia skill changes. Treatment should focus on activities designed
progresses, the lack of skill generalization and maintenance, to enhance feelings of control by addressing the most
and the social validation of treatment outcomes. obvious symptom of dementia-the memory deficits. Be-
cause external memory aid techniques hold the most prom-
ise for generalized and maintained skill use, it is recom-
Selecting Treatment Targets mended that treatment begin by having a patient identify as
The choice of a treatment target is critical to intervention many specific examples/incidents of memory failure as pos-
outcome. To maximize treatment effects, one should choose sible, organizing them into topical categories, and finally
functional communication skills3 that directly and significantly choosing memory aids appropriate to his or her cognitive and
environmental situation. In the home environment, a patient
may be best served by practicing specific habits for retrieval
3
This definition of functional communication differs from that of Holland (1980),
whose formal test of functional communication, Communicative Abilities in
Daily Living (CADL), identifies a wide variety of pragmatic skills such as an and divergencies, many of which may not be realistic treatment goals for the
appreciation of humor and metaphor, role-playing, sequential relationships, patient with dementia.

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 Bourgeois: Communication Treatment for Dementia 839

of important information (i.e., consulting memo board, calen- treatment that will maintain unsupported until the person dies
dar, notebook, memory wallet, telephone directory, etc.). from the disease; it will be necessary to change expectations
In the middle stages, the patient loses awareness of the for maintenance. Studies are needed that will demonstrate
severity and extent of memory problems. He or she may the relative maintenance of treated skills over time when
have become a proficient user of a memory wallet or note- compared with the constant decline of untreated behaviors. It
book earlier, but now may not remember to use it. Such is necessary to question whether, and for how long, treat-
patients can still benefit from external memory aids as long ment will retard the rapid course of deterioration that is
as additional prompts are provided and the use of the aids expected. Even so, it is not clear that maintenance of a skill
has been incorporated in the daily routine. The caregiver at a less-than-optimal but stable level will be valued by
needs to be trained to be the communication facilitator, using caregivers and family. Caregivers need to identify a hierarchy
appropriate prompts to stimulate appropriate communicative of skills that they wish to see maintained.
responses.
In the late stages, when the patient becomes increasingly
mute, or communication can best be described as incoher- Ethical Issues
ent, bizarre, or echolalic, intervention should be caregiver
focused. Improvements in communicative interactions are Although speech-language pathologists are familiar with
possible when caregivers understand how to provide the the language and communication deficits of dementing pa-
stimuli that will prompt positive changes in a patient's non- tients, their role is typically limited to participating in the
verbal and verbal behaviors. Preliminary evidence (Bour- differential diagnosis of these individuals. A number of rea-
geois, 1990b) suggests that even severely demented individ- sons why speech-language pathologists have not intervened
uals, whose only communication is a constant barrage of with elderly adults with dementia include the purported
unintelligible syllables, have been able to utter intelligible and inability of patients to learn new behaviors, and/or to maintain
appropriate words when shown large print-labeled picture treatment gains; the degenerative nature of their disease
stimuli of familiar family members and events. process that contraindicates expenditure of time and money
for questionable gains; and the value of raising client and
family expectations for improvement when the degenerative
Generalization and Maintenance Issues course of the disease cannot be altered (Golper & Rau,
1983). Although convincing evidence exists that individuals
The lack of generalization and maintenance of behavior with dementia may have treatment potential, skeptics will
changes in this literature presents a challenge. Failure of question the value of an intervention that is not designed to
treatment effects to generalize has been identified by Labou- reverse the course of a disease, or that will need continuous
vie-Vief et al. (1974) as one of the major, and as yet largely support from others inthe environment to be successful. The
unresolved, problems of psychotherapeutic and psychoedu- ultimate decision to treat or to withhold treatment is left up to
cational interventions with the elderly. Needless to say, the family once professionals have given their opinions about
treatment with this population cannot be justified unless time potential outcome. The final test of whether treatment of
and effort expended result in measurable effects for a rea- communication deficits with this population will be accepted
sonable length of time. as necessary is the evaluation by caregivers and family that
The application of strategies to ensure generalization observable and meaningful changes occurred as a result of
(Stokes & Baer, 1977) may be necessary to produce endur- treatment. They must be convinced that these changes
ing treatment effects. One such technique, programming significantly alter the quality of life of the individual and/or his
common stimuli (Stokes & Baer, 1977), may be particularly or her caregiver by prolonging the patient's ability to perform
relevant to the treatment of adults with dementia. In this certain tasks, or by making the patient's attempts to commu-
procedure, salient stimuli or cues common to or highly nicate less frustrating and more rewarding. More research is
related to both training and generalization settings are incor- needed to determine the conditions under which family
porated into treatment procedures and training stimuli. Bour- members will take an active therapeutic role because they
geois (1990a) suggested that generalized responding in her find their efforts worthwhile. Conversely, the point at which
study was the result of training the use of a common constant prompting of the patient begins to contribute addi-
stimulus, a communication wallet that patients carried with tional burden and stress to the caregiver needs to be
them into different settings to use with multiple partners. identified.
More research is needed to evaluate the extent of generali- Social validation procedures (Kazdin, 1982; McMahon &
zation of trained behaviors when stimuli, or prompts, remain Forehand, 1983; Wolf, 1978) should be integrated into every
in the training setting or are transported to multiple settings. treatment research protocol to determine the extent to which
No evidence exists to date on long-term maintenance of society supports intervention efforts. Simple, direct question-
therapeutic gains with dementing individuals. This is not naires eliciting opinions about treatment effects and percep-
surprising because of the degenerative course of the disease tions of quality of life will help to evaluate intervention efforts.
and because knowledge of what might be a robust treatment Bourgeois (1990a) included a social validation procedure in
is just developing. Nevertheless, even when technology her investigation of a memory aid treatment for improving
becomes sophisticated enough to produce socially valid conversational skills of AD patients, with conflicting results.
treatment gains, expectations for maintenance of these gains Although professional judges consistently rated patients'
have to be realistic. It may never be possible to develop a posttreatment conversations as significantly improved over

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 840 Journal of Speech and Hearing Research 34 831-844 Augus 1991

baseline conversations on eight dimensions, the caregivers treatment strategies within the general frameworks outlined
either did not detect improvements or the changes did not (e.g., environmental arrangement, and/or controlling ante-
alter perception of caregiver burden. This discrepancy may cedent and consequating stimuli) and the subsequent cou-
have been due to caregivers' unrealistic expectations for pling of these strategies into comprehensive treatment pack-
treatment outcome, limited use of the aid during conversa- ages. Further, an understanding that "therapy with this
tions with patients, and ability to interpret utterances that population serves to maintain functioning and to reduce
unfamiliar listeners would find unintelligible. Caregivers have symptoms rather than have any curative properties"
to help professionals by articulating treatment expectations; (Gilewski, 1986, p. 291) should stimulate the development of
conversely professionals should guide caregivers in choos- humane procedures to enhance the quality of life of dement-
ing realistic treatment goals. Cooperative efforts of this sort ing patients and their caregivers.
should result in ethical and humane choices for dementia
patients.
Acknowledgments
Research Needs This research was supported by Alzheimer's Disease and Related
Disorders Association Grant IIRG-88-078 to Eye and Ear Institute of
Speech-language pathologists are uniquely qualified to Pittsburgh. The editorial comments of Dr. Howard Goldstein and Dr
make significant contributions to the many existing therapies Connie Tompkins are gratefully acknowledged.
and to develop new interventions that either target or use
communication skills as the vehicle for therapeutic change.
Systematic replication and extension of existing studies are References
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600-605. thedral of Learning, Pittsburgh, PA 15260.

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