Royal College of Speech & Language Therapists Clinical Guidelines: 5.10 Disorders of Mental Health & Dementia

Taylor-Goh, S. (ed). (2005).

Bicester (United Kingdom): Speechmark Publishing Ltd., 83-91.

This guideline provides recommendations for the assessment and management of communication and swallowing in children and adults with mental health conditions, including dementia and psychiatric disorders. The target audience of this guideline is speech and language therapists.

Royal College of Speech & Language Therapists (United Kingdom)

<div>The speech-language pathologist will determine the appropriate behavioral strategies for safe oral intake and communicate recommendations to carers of individuals with dementia (Grade A Evidence).</div>

<div>For children and adolescents with mental health disorders, core speech and language levels (i.e., verbal, non-verbal, receptive, and expressive language skills) should be assessed and particular emphasis should be placed on:</div> <ul> <li>the use of language and pragmatics (e.g., to look for a delay in acquisition or disordered use of skills),</li> <li>specific language features such as paraphasias or neologisms,</li> <li>discourse analysis to ascertain presence of features such as derailment or circumlocution,</li> <li>amount and relevance of content,</li> <li>topic, and</li> <li>sequencing (particularly when acute episodes of mental illness are present) (Level B Evidence; p. 85).</li> </ul>

<div>Group therapy may be appropriate to stimulate language and communication. It may be interdisciplinary and may target language directly or encourage communication through activity (Grade C Evidence).</div>

<p>Grade B evidence suggests that in addition to evaluating the individual's core communication skills, the following aspects should be considered:</p> <ul> <li>case history (including onset and progression of the problem),</li> <li>pragmatics and discourse,</li> <li>inadequate use of referents,</li> <li>repetition of topics or questions,</li> <li>paucity of speech,</li> <li>difficulty with turn-taking,</li> <li>non-verbal skills,</li> <li>difficulties associated with topic maintenance or topic change,</li> <li>confabulation or evidence of memory disturbance,</li> <li>verbal fluency and visual confrontation naming,</li> <li>intelligibility,</li> <li>sequencing ability,</li> <li>verbal reasoning,</li> <li>the environment,</li> <li>the family,</li> <li>comprehension at the sentence and word level, and</li> <li>reading aloud and reading for meaning.</li> </ul>

<div>Assessments should be conducted across settings, and time of day, over varying periods of time, with several different speakers in order to discern variability in the individual's performance (Grade B Evidence).</div>

<div>For moderate to advanced dementia, interventions should focus on facilitation of verbal and non-verbal communication skills using a variety of techniques such as life-history books, memory aids, reminiscence groups, Sonas conversation groups, and sensory stimulation (Grade B Evidence).</div>

<div>The SLP should assess the communication environment and make environmental modifications as appropriate (Grade C Evidence).</div>

<div>Caregiver training should focus on facilitating communication and can be offered individually or in groups. The training may be in the form of workshops, role-play, information-giving, or formal education (Grade C Evidence).</div>

<div>For individuals with early stage dementia, intervention should focus on the strengths and weaknesses of the individual and the associated emotional impact these have on the individuals and caregiver. Specifically, working on conversation may enhance communication (Grade B Evidence).</div>

<div>Swallowing assessment should include a detailed case history paying particular attention to sudden onset and weight loss. The effects of mood and behavior, environment, medication, attitude, posture and capacity for treatment should also be evaluated to determine impact on eating and swallowing (Grade B Evidence).</div>

<div>Interventions should also focus on caregiver education/counseling to establish communication expectation and strategies (Grade B Evidence).</div>

<p>To assist with differential diagnosis, grade B evidence suggests that the clinical evaluation should include consider the following factors that may contribute to communication impairments for individuals with suspected dementia:</p> <ul> <li>attention and concentration,</li> <li>sensory impairment,</li> <li>mood, motivation, and behavior,</li> <li>insight,</li> <li>immediate, recent, long-term, and new-learning memory,</li> <li>registration, recall, and reasoning,</li> <li>the environment,</li> <li>communication skills of others, and</li> <li>the attitude or philosophy of caregivers.</li> </ul>