Über die Autorin bzw. den Autor

Karen Bryan is a Professor of Clinical Practice at the European Institute of Health and Medical Sciences, University of Surrey, UK. Her current research interests include development of the Barnes Language Assessment, care sector training and education and practice development for the healthcare workforce.

Jane Maxim is Head of Department and Professor of Language Pathology at the Department of Human Communication Science at University College London.  She has a particular interest in language breakdown in different forms of dementia.

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Communication Disability in the Dementias

Edited by Karen Bryan, European institute of Health and Medical Sciences, University of Surrey and Jane Maxim, Department of Human Communication Science, University College London.

Focusing on language and communication issues of older people with mental health problems, and based on the editors' earlier book, Communication Disability and Psychiatry of old Age, this book recognizes the many changes that have occurred in the last decade in relation to speech and language therapy practice. During this time there have been substantial advances in the diagnosis and treatment of dementias and a growing awareness of the need to treat older people appropriately. There is now recognition that speech and language are not just the business of the speech and language therapist but involves all t members of the multidisciplinary team who are dealing with those who have mental difficulties.

The book includes examples of evidence-based practice and is well referenced throughout. It discusses developing new services for older people and extending existing ones to help those with mental health problems maintain their independence and to help minimize the degenerative disease processes or as long as possible.

Aus dem Klappentext

Communication Disability in the Dementias

Edited by Karen Bryan, European institute of Health and Medical Sciences, University of Surrey and Jane Maxim, Department of Human Communication Science, University College London.

Focusing on language and communication issues of older people with mental health problems, and based on the editors' earlier book, Communication Disability and Psychiatry of old Age, this book recognizes the many changes that have occurred in the last decade in relation to speech and language therapy practice. During this time there have been substantial advances in the diagnosis and treatment of dementias and a growing awareness of the need to treat older people appropriately. There is now recognition that speech and language are not just the business of the speech and language therapist but involves all t members of the multidisciplinary team who are dealing with those who have mental difficulties.

The book includes examples of evidence-based practice and is well referenced throughout. It discusses developing new services for older people and extending existing ones to help those with mental health problems maintain their independence and to help minimize the degenerative disease processes or as long as possible.

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Communication Disability in the Dementias

John Wiley & Sons

Chapter One

Karen Bryan and Jane Maxim

Population issues

Across the EU, people over 65 form 17% of the population (ONS 2002a). The UK had a population of 59.2 million at the last census in 2001. For the first time, people over 60 form a larger part of the population (21%) than children under 16 (20%). There has also been a large increase in the number of people over 85: now 1.1 million, which is 2% of the population. In England and Wales there are 336 000 people aged 90 and over, and of these nearly 4000 are providing 50 or more hours of care to another family friend or carer.

Older people receive a large proportion of health and social care spending. In 2000, 28 billion were spent on hospital and community care with nearly two-fifths of this spend on people aged 56 and over (ONS 2001). In England and Wales, 5.2 million people provide informal care, including a million who provide more than 50 hours a week and 1.6 million who are in full-time work.

A major public health issue for the next century is the increase in the number of older people in the UK from ethnic minority groups (OPCS 1993). As of 2000, the largest ethnic group was Indian (984 000 people), then Caribbean and African descent (969 000) and Pakistani and Bangladeshi descent (932 000). Initiatives for these groups have tended to focus on physical health, and this together with the traditional stigma of mental illness in some ethnic groups has led to the relative neglect of older people from ethnic minorities (Rait et al. 1996). The term 'triple jeopardy' has been used to describe the challenges of racism, ageism and in some cases socio-economic deprivation faced by older people from ethnic minority backgrounds (Norman 1985).

Who are older people and where do they live?

Single-pensioner households make up 14.4% of all households, and more than two thirds of these have no access to a car. Many older people live alone: 52.5% of women and 25.7% of men aged 75-84, and 54.5% of women and 36.9% of men aged 85 and over.

The number of places in residential care for older people peaked at 247 000 in 1998, but fell to 237 000 in 2001 due to a levelling off of places available in the private sector and continued reduction in public sector places (ONS 2002b). Around 2 million children or children-in-law provide informal care to older adults living in another household and that figure has remained relatively stable between 1985 and 1995, although there has been a shift from children as the most likely carers to spouses. However there has been a 25% decline in intergenerational care within the same home. This is thought to be associated with trends such as more women working outside the home and the previous rise in institutional care (Pickard 2002).

Attitudes to older people and their health

Greengross et al. (1997) described ageing as a subject that should be top of world agendas. There are more older people living longer with increasingly fewer resources to care for them. Shifts in government policy in developed countries have encouraged preservation of independence. Emphasis is being placed upon providing support to enable people to live with age-related degenerative conditions such as dementia (Benbow and Reynolds 2000). Care of older people is a recognized specialism within medicine and other health professions. Another positive development is that age discrimination is considered a negative factor to be avoided and age is not now a valid criterion to restrict access to services (National Service Framework for Older People, DH 2001). Much has been written about the benefits of preventive care and the need to manage degenerative difficulties rather than accept them as an inevitable consequence of older age. For example, the effects of reduced hearing on communication and psychosocial functioning are recognized (Heine and Browning 2002) and studies have shown that intensive support for older people with hearing difficulty produces significant improvements in social functioning (Sherbourne et al. 2002).

The boundary between cognitive changes associated with normal ageing and those associated with dementia is accepted as unclear (Figure 1.1). The Nun study showed that education may function as a buffer to protect against the effects of dementia on ageing (Snowdon et al. 1996). However, the study also showed that pathological changes associated with Alzheimer's disease are present in the brains of those older sisters who do not show dementia, suggesting that other factors such as environment and lifestyle may mediate in pathological processes (Stern et al. 1994). These findings are helpful in encouraging professionals to take positive attitudes towards the support and care of older people with dementia. In Chapter 3 we look at the contribution of general practice and in Chapter 9 at measures to support carers; Chapter 7 examines whole-system approaches to dementia.

Overview of language and ageing

Age-related reduction in cognitive functioning (including language) has received much attention in recent years (see Nussbaum et al. 1996 for a review of ageing and communication). The traditional view of decline in functioning across the board has long since been shown to be an inaccurate and simplistic view. Losses and gains are now considered, with age-related decline often a function of the exact task. For instance, recognition of pictures and completion of word stems have been convincingly shown to be age-invariant memory tasks (Park 2000). Salthouse (1991) described four mechanisms hypothesized to account for age-related differences in cognitive functioning:

speed at which information is processed

working memory function

inhibitory function (affecting the ability to focus by inhibiting unwanted information)

sensory function.

These factors need to be distinguished from actual changes in language functioning. The effects of health problems such as cardiac or peripheral vascular disease on cognitive functioning also need to be distinguished from normal ageing (Elwood et al. 2002).

A further important factor is individual variation. Parameters such as education, experience and cognitive style will influence the effects of ageing. Christensen (2001) reported, from an extensive longitudinal study of older people in Australia, that education, good health, genetic factors (such as absence of the APOE epsilon4 allele) and activity were protective of cognitive decline, and that diversity in cognitive ageing suggests that more than one process may be operating to produce cognitive decline. Butler et al. (2004) reviewed the evidence for cognitive decline in normal ageing and concluded that social engagement, intellectual stimulation and physical activity play a key role in maintaining cognitive health and preventing cognitive decline. Factors such as circadian rhythms may also influence processing. Yoon (1997) found that older people's preference for reading the paper and shopping first thing in the morning related to their tendency to be more energetic and mentally alert in the morning.

Age-related changes in cognitive functioning may also result in developmental 'gains' (Dixon 2000):

Gains despite or independent of constraints provided by losses, e.g. logical, abstract thinking (Sinnott 1996) and the concept of 'wisdom' (Baltes and Staudinger 1993) are thought to emerge post young adulthood.

Gains as losses of a lesser...