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Article Excerpt
The Academy of Neurologic Communication Disorders and Sciences (ANCDS), the American Speech-Language-Hearing Association (ASHA), its Special Interest Division 2 (SID-2, Neurophysiology and Neurogenic Speech and Language Disorders), and the Veterans Administration (VA) collaborated to establish evidence-based practice guidelines for speech-language pathologists working with individuals with Alzheimer's disease (AD). A writing committee was formed and generated a technical report with evidence tables based on systematic review and classification of literature related to assessment and use of direct and indirect interventions with individuals with AD. This clinical report includes a summary of the scientific evidence related to one type of indirect intervention: educating caregivers about AD and training them to use strategies to enhance communicative effectiveness. Seven studies were reviewed and judged to provide Class I, II, and III evidence to support the education and communication training of family and professional caregivers of individuals with AD. Participant characteristics, nature of the education and training programs, outcomes, methodological concerns, trends across studies, and recommendations for clinical practice as well as future research are discussed.
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The Dementia Practice Guidelines Writing Committee was formed as a collaboration between the Academy of Neurologic Communication Disorders and Sciences (ANCDS), the American Speech-Language-Hearing Association (ASHA), and the Veterans Administration (VA) to establish evidence-based practice recommendations for speech-language pathologists working with individuals who have Alzheimer's-type dementia (see Bayles et al., 2005 for more information on the committee).
Weiner (1996) defines dementia as "a reduction or impairment of multiple cognitive abilities, including memory, sufficient to interfere with self-maintenance, work, or social relationships" (p. 3). Alzheimer's disease, the most prevalent form of irreversible dementia, currently affects more than 4.5 million Americans (Hebert, Scherr, Bienias, Bennett, & Evans, 2004). As the disease progresses, affected individuals require care and supervision to safely and adequately meet daily needs. Effective communication between individuals with AD and caregivers, both family and professional, is important for meeting basic and social needs (Hopper, Bayles, Harris, & Holland, 2001). However, many caregivers lack knowledge of how to facilitate communication with individuals with AD. Speech-language pathologists have a role in educating caregivers about AD and related dementias and methods to improve communication with individuals who have AD. The goal of this article, which is one of a series of reports, is to summarize the state of evidence regarding caregiver training in communication strategies to improve interactions with individuals who have AD.
PROCEDURES
Systematic Review of the Literature
A general search was conducted in several electronic databases: Medline (1966-August 2002), Psych-Info (1967-August 2002), and Language and Linguistic Behavioral Abstracts (1960-August 2002). Hand searches were also conducted of relevant studies cited in articles. The following search terms were used: Alzheimer's/Alzheimer disease, dementia of the Alzheimer's type, dementia, caregivers, caregiver education, communication, and caregiver intervention.
For the purposes of this systematic review, investigators included only those studies in which researchers specifically assessed the effect of interventions involving education to family and professional caregivers about Alzheimer's disease/dementia and training in communication strategies. Articles that did not specifically address individuals with AD or a related dementia were excluded from this review. In total, six studies met inclusion criteria and were reviewed and classified.
Classifying the Evidence
The committee developed an evidence table for classifying research evidence pertaining to speech-language pathology interventions for people with AD. Data from the six studies on caregiver education and training in communication strategies were entered into the evidence table (see the technical report and associated evidence table at www.ancds.org). Each study was reviewed based on several parameters, including the purpose of the study, subject characteristics, internal, external, and content validity, dose-response characteristics (frequency, intensity, duration) of intervention, outcome measures used to document intervention effects and study results. Each article was rated independently by two members of the writing committee to ensure reliability of coding.
DESCRIPTION OF THE STUDIES
In the first two studies, Ripich (1994) and Ripich, Wykle, and Niles (1995) investigated the effects of a caregiver communication training program called the FOCUSED program on three caregiver-related outcomes: (a) knowledge of communication and strategies, (b) attitude toward communication with individuals with AD, and (c) coping and quality of visits between caregivers and persons with AD. Participants were 17 nursing assistants in a long-term care facility (16 females and one male; ages 20-69; 11 mean years of education; 14.25 mean years of experience). Treatment consisted of six weekly 2-hour training sessions. The training sessions were divided into six modules:
1. information about AD and associated communication deficits,
2. differences among normal forgetting, depression, and AD,
3. value of interpersonal skills in caring for residents with AD,
4. cultural and ethical considerations,
5. stages of AD, concurrent communication characteristics, and ways to maximize communicative ability at each stage, and
6. use and evaluation of FOCUSED strategies.
FOCUSED is an acronym for the key features of the communication enhancement program: F = functional and face-to-face; O = orient to topic; C = continuity of topic-concrete topics; U = unstick any communication blocks; S = structure with yes/no and choice questions; E = exchange conversation--encourage interaction; D = direct, short, simple sentences. Written materials, including a training guide and reminder cards of the FOCUSED strategies, were provided to the nursing assistants. Trainers were a certified speech-language pathologist and an assistant director of nursing.
The outcome measures used to assess program effects included a knowledge survey and an attitude survey administered before and after the program participation. Caregivers showed increased knowledge across all areas trained, with significant gains in modules 5 and 6 (stages of AD, concurrent communication characteristics, and ways to maximize communication at each level; use and evaluation of FOCUSED strategies). Caregivers also reported improvement in their attitudes toward and satisfaction of communication with residents with AD.
In a third follow-up study, Ripich and Ziol (1999) investigated whether the FOCUSED program altered the types of questions (yes/no, choice, and open-ended) used by family and professional caregivers, whether these question types affected the success of communication with persons with AD, and whether reinforcement of training results in better maintenance of communication strategies over time.
Participants were 54 dyads consisting of family caregivers and individuals with early to moderate stage AD, diagnosed using criteria established by the National Institute of Neurological and Communicative Disorders and the Alzheimer's Disease and Related Disorders Association (NINCDS-ADRDA; McKhann et al., 1984). Individuals with AD had a mean MMSE score of 16.89. No other demographic information was provided. Vision and hearing status were not addressed. Family caregivers were divided into three groups: two experimental groups (FOCUSED group and FOCUSED-Booster group) and...
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