Problems communicating with and understanding others may be signs of dementia. Pharmacists, as accessible health care professionals who verbally interact with seniors, may be in a position to notice communication problems and raise the possibility of language difficulties (TABLE 1) secondary to dementia or other contributing factors. In the early stages of dementia while comprehension is still intact, clear expressive language such as finding the right word—including familiar ones—may become problematic.1 The patient may become frustrated at times, and family members and friends may become concerned, if they notice these subtleties at all. Later in the course of the disease, while still knowing what they want to say, patients may find it difficult to formulate understandable sentences; this is known as expressive dysphasia.1 Ruling out other potential causes of communication difficulties or contributing factors in seniors is imperative. Overall, when a senior who used to speak fluently now stumbles over words, it is likely that it is not attributable to “old age” but rather to an important neurologic condition.2,3
Importance of Language Assessment
Dementia represents a significant impairment in cognitive functioning, and is defined as a decline in memory and at least one other cognitive domain serious enough to interfere with daily life and not accounted for by other medical conditions. The most common other domains are impaired executive functioning (i.e., organizing and self-regulating), aphasia (i.e., impaired ability to comprehend or use language), or agnosia (i.e., impaired ability to identify objects despite intact sensory function).4-6 In establishing whether or not a person has dementia, difficulties in thinking, attention, and calculation are assessed.2,3 To do this, it is necessary to evaluate language since it is used to inquire about all aspects of cognition and establish the extent of impaired brain function.2-4 For example, a screening measure such as the Mini Mental State Examination (MMSE) may be used, requiring a patient to attempt naming, repeating, following a sequence of commands, and writing a sentence. Further, during the course of an interview, language can be observed critically since a variety of language difficulties may be detected during spontaneous conversation with a patient; pharmacists may notice these difficulties during a counseling session or during a medication-therapy management encounter. Once cognitive status is determined, appropriate measures—including medical, pharmacologic, and nonpharmacologic—and caregiver guidance may be undertaken to tailor the care for the affected individual. Avoiding medications that may alter cognition and potentiate the risk of delirium in seniors should also be considered.
Primary Progressive Aphasias
Primary progressive aphasia, a clinical syndrome defined by progressive deficits isolated to speech and/or language, is classified as either semantic dementia (SD) or progressive nonfluent aphasia (PNFA).4,7 SD involves severe and progressive problems with naming, category fluency, and picture naming and comprehension, among others. PNFA involves poor expressive language with hesitant speech accompanied by poor articulation, dysarthria (impaired speech secondary to muscular-control disturbances), and profound word-finding difficulty not accounted for by stroke.4 For a detailed discussion of these and other forms of dementia, including screening tools and diagnostic and referral information, see Reference 4.
Research is ongoing with regard to speech and language related to memory and aging. Findings of a recent study indicate that a multidimensional quantification of connected speech production is necessary to characterize the differences between the speech patterns of the variants of primary progressive aphasia adequately—not just simply as “fluent” or “non-fluent”—and to identify the associations between certain aspects of connected speech and specific components of the neural network for speech production.7
Other Contributing Factors
Compromised communication in seniors may also be secondary to visual and hearing impairment. Approximately 30% of the population over 65 years of age has hearing impairment; this figure rises to 40% to 50% in persons over the age of 75 years and greater than 80% in persons over 85 years of age.8 Of note, the prevalence of hearing loss is higher among persons with dementia than among those without it.8 Further, the behavioral implications of the hearing and speech difficulties characterizing older adults are considerable; many dimensions of quality of life are affected including functional status and cognitive and emotional function.8
Dementia may be associated with other medical conditions, such as infectious disorders, head trauma, and metabolic disorders.9 For a discussion of dementia in these conditions, see Reference 9.
Pharmacists should screen for medications that impair cognition, including those with a high anticholinergic burden. Older people are more susceptible to anticholinergic effects of medications owing to the significant age-related reduction in cholinergic neurons or receptors in the brain; impaired hepatic and renal clearance of medications; and the increase in blood-brain barrier permeability, particularly in acute physical illness.10 Additionally, awareness of the fact that medications have the potential to alter the voice is helpful in distinguishing medication-related vocal changes; examples, according to the National Center for Voice and Speech, are listed in TABLE 2.11,12 While low literacy and illiteracy should not be overlooked when communication difficulties arise during an encounter, they should not be attributed solely to them without ruling out the other potential contributing factors as well.
Conclusion
Compromised communication in seniors may indicate the early phase of dementia, or may be due to other contributing factors, including medications, commonly seen in the elderly. Pharmacists can make a difference in the lives of patients and their caregivers by contributing to the identification, assessment, and referral for evaluation of language difficulties related to dementia. When communication problems are identified and addressed, an appropriate care plan for a multifaceted approach to care is better achieved.
REFERENCES
1. Pulsford D, Thompson Rachel. Dementia: Support for Family and Friends. London, England and Philadelphia, PA: Jessica Kingley Publishers; 2013:19-20.
2. Rockwood K, MacKnight C. Understanding Dementia: A Primer of Diagnosis and Management. Halifax, NS: Pottersfield: 2001:75-78.
3. Dementia guide. About dementia. Updated April 15, 2013. www.dementiaguide.com/aboutdementia/understanding/language_difficulties/. Accessed April 18, 2013.
4. Sewell MC, Vigario A, Sano M. Neuropsychology in the diagnosis and treatment of dementia. In: Fillit HM, Rockwood K, Woodhouse K, eds. Brocklehurst’s Textbook of Geriatric Medicine and Gerontology. 7th ed. Philadelphia, PA: Saunders Elsevier; 2010:402-410.
5. What is executive function? WebMD.com. Reviewed April 12, 2012. www.webmd.com/add-adhd/executive-function. Accessed April 24, 2013.
6. Dementia. Neurologic disorders. The Merck Manual. Updated November 2012. www.merckmanuals.com/professional/neurologic_disorders/delirium_and_dementia/dementia.html. Accessed April 24, 2013.
7. Wilson SM, Henry ML, Besbris M, et al. Connected speech production in three variants of primary progressive aphasia. Brain. 2010;133(pt 7):2069-2088.
8. Weinstein BE. Disorders of hearing. In: Fillit HM, Rockwood K, Woodhouse K, eds. Brocklehurst’s Textbook of Geriatric Medicine and Gerontology. 7th ed. Philadelphia, PA: Saunders Elsevier; 2010:822-834.
9. Camicioli R, Rockwood K. Dementia diagnosis. In: Fillit HM, Rockwood K, Woodhouse K, eds. Brocklehurst’s Textbook of Geriatric Medicine and Gerontology. 7th ed. Philadelphia, PA: Saunders Elsevier; 2010:385-391.
10. Do anticholinergics lead to further cognitive decline? Medscape Education Clinical Briefs. Medscape.com. October 11, 2011. www.medscape.org/viewarticle/751312. Accessed April 17, 2013.
11. Medications that affect voice. National Center for Voice and Speech. www.ncvs.org/rx.html. Accessed April 15, 2013.
12. Epocrates, Version 4.5. Epocrates, Inc. www.epocrates.com. Accessed April 14, 2013.
13. Bridges BJ. Therapeutic Caregiving: A Practical Guide for Caregivers of Persons With Alzheimer’s and Other Dementia Causing Diseases. Mill Creek, WA: BJB Publishing; 1998.
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