Abstract
Primary progressive aphasia describes a group of language-led dementias that affects an individual’s ability to speak, comprehend, read and write. While post-stroke aphasia has been the subject of extensive research, particularly in the domain of communication strategies, the same level of research interest has not been observed in PPA. This is indicative of a significant knowledge gap regarding effective communication strategies in PPA. The present review aims to outline the current research evidence related to the range of communication strategies employed within PPA individuals and their effectiveness. A series of studies were considered, encompassing patients diagnosed with PPA, their spouses and/or other communication partners, provided that data on the utilization and training of communication strategies was addressed. A total of 26 non-experimental and experimental studies met the inclusion criteria. Communication strategies retrieved varied from verbal, to non-verbal, environmental modification strategies and partner adaptation strategies. The findings demonstrate that assistive augmented communication strategies have a positive impact on communication interactions. Furthermore, the multiple use of different modalities ensures the optimal conveyance of messages. Consequently, the degree of independence exhibited by the subjects increases, as does their overall quality of life.
Keywords
Introduction
In recent decades, there has been a growing interest in neurodegenerative conditions due to the irreversibility of symptoms, the lack of effective treatments, and the associated social and economic burdens (Hung et al., 2010). Individuals with neurodegenerative conditions require substantial assistance with activities of daily living (ADLs), including eating, drinking, dressing, bathing, personal hygiene, use of the toilet, and transportation (Maresova et al., 2020).
Frontotemporal lobar degeneration (FTLD) and Alzheimer’s disease represent examples of early-onset dementias (Jarmolowicz et al., 2014). Both FTLD and Alzheimer’s disease frequently present with primary progressive aphasia (PPA) (Bergeron et al., 2018). Clinicopathological correlations in PPA, thus, reflect the contributory role of Pick’s disease and other tauopathies, such as corticobasal degeneration, progressive supranuclear palsy, corticobasal degeneration, motor features of amyotrophic lateral sclerosis that are associated with TDP-43, dementia with Lewy bodies or proteinopathies (Grossman, 2010).
PPA is diagnosed when there are prominent deficits in language functions that have a detrimental impact on ADLs. In the initial two-year period, aphasia is typically accompanied by relatively preserved cognitive abilities (Gorno-Tempini et al., 2011). PPA can be subdivided into three main variants, which are distinguished by their distinctive speech and language profiles, patterns of brain atrophy, and underlying pathologies (Butts et al., 2015). This means that each PPA clinical variant is associated with a typical and most frequent cognitive, neuroimaging, and neuropathological profile (Spinelli et al., 2017).
Semantic variant of PPA (svPPA) is characterized by impaired confrontation naming, impaired single-word comprehension, impaired object knowledge and surface dyslexia or dysgraphia. In svPPA, a predominant anterior temporal lobe atrophy and/or anterior temporal hypoperfusion or hypometabolism is observed on single-photon emission computed tomography (SPECT) or positron emission tomography (PET) (Gorno-Tempini et al., 2011). Research conducted in the clinical and pathological domain has demonstrated a link between the presence of svPPA and the manifestation of TAR DNA-binding protein 43 (TDP-43) pathologies (Bergeron et al., 2018). In non-fluent or agrammatic variant (nfvPPA), agrammatism in language production is evident, comprehension of syntactically complex sentences is impaired, and apraxia of speech may manifest. Neuroimaging reveals a predominant left posterior fronto-insular atrophy on magnetic resonance imaging (MRI) or left posterior fronto-insular hypoperfusion or hypometabolism on SPECT or PET scans (Gorno-Tempini et al., 2011). Corticobasal degeneration and Pick’s disease have been demonstrated to be significantly associated with nfvPPA (Bergeron et al., 2018). In logopenic variant PPA (lvPPA), individuals experience difficulties in retrieving words, as well as repeating sentences and phrases. Additionally, speech errors are observed in spontaneous speech and naming tasks. MRI of individuals with lvPPA reveals predominant atrophy in the left posterior perisylvian or parietal regions, as well as reduced perfusion or metabolic activity in these regions, as indicated by SPECT or PET scans (Gorno-Tempini et al., 2011). Amyloid pathology has been identified as a frequently underlying pathology in cases of lvPPA (Bergeron et al., 2018). As previously stated, communication is the most significantly affected ability due to the gradual deterioration of language skills, particularly in word-finding and spelling (Mesulam et al., 2012). To circumvent communication breakdowns due to the damaged system, intact systems or skills are recruited for the purpose of training compensatory strategies (Hopper, 2007). A further objective of behavioural interventions may be to assist communication partners in providing more effective support for communication interactions (O’Rourke et al., 2018).
Volkmer and collaborators (Volkmer et al., 2020) emphasised the pivotal role of individuals’ existing communication strategies and the practice of these strategies with caregivers in the context of functional communication interventions. One might posit that communication strategies represent the way individuals with aphasia and their respective conversation partners successfully overcome the communication barriers imposed by aphasia (Beckley et al., 2017). Verbal and non-verbal communication strategies may include the use of circumlocution, keywords, signing, gesturing, pantomime, drawing, writing, conversation continuers (e.g., ‘mm hum’), communication charts, and high- or low-tech communication aids (Beeke et al., 2015; Hux et al., 2008; Sandt-Koenderman, 2004; Wilkinson et al., 2011). Prior to offering a concise characterisation of high- and low-tech communication aids, it is imperative to comprehend the concept of Augmentative and Alternative Communication (AAC). This term encompasses a diverse array of tools, techniques, strategies, environmental and partner adaptations, and behavioural modifications. The purpose of AAC is to compensate for the loss of speech and language function (Fried-Oken et al., 2010). The range of communication aids extends from low-tech to high-tech AAC. Low-tech AAC refers to communication techniques that do not rely on electronic or computerized devices, such as using pen and paper, alphabet boards, communication books, alerting systems, writing messages, drawing pictures, pointing words or basic signaling tools to help individuals express themselves (Fried-Oken et al., 2015). In contrast, high-tech AAC refers to technologically advanced communication tools and systems (Russo et al., 2017), such as speech-generating devices (Fried-Oken et al., 2015).
Regarding PPA, there is a paucity of knowledge regarding the type of communication strategies employed in conversations and/or trained during the intervention period. Furthermore, the extent to which these strategies are effective is also unclear. Accordingly, the objective of this exploratory study is to systematically map the breadth of literature on communication strategies used and/or trained in the PPA population, identify key concepts, theories, sources of evidence and knowledge gaps.
Method
To ascertain whether any existing reviews addressed communication strategies and/or training in PPA, a brief search of PROSPERO, the Cochrane Database of Systematic Reviews and JBI Evidence Synthesis was conducted. No reviews were identified on this topic. Prior to the commencement of the study, a protocol was devised which set out the objective, search strategy, eligibility criteria, procedures for evidence collection and data extraction. The protocol was duly registered with Figshare (reference: 10.6084/m9.figshare.25465222). The process was informed by the Preferred Reporting Items for Systematic Review and Meta-Analysis Extension of Scoping Reviews Checklist (PRISMA-ScR) throughout, with decisions made in accordance with its tenets (Tricco et al., 2018) (Annex I). Furthermore, the Joanna Briggs Institute recommendations were adhered to enhance the methodological quality of the study (Pollock et al., 2023). Two researchers were involved in the review. The following section outlines the methodology employed in the review process, including the search strategy, eligibility criteria, study selection, data extraction, reviewer reliability, data analysis and presentation.
Eligibility Criteria (Participants, Concept, Context, Types of Sources)
In accordance with the recommendations, the authors of the scoping review employed the Population, Concept and Context (PCC) framework as a guide to determine the eligibility criteria (Peters et al., 2020).
Participants
This review considered studies that included persons with PPA (pwPPA) or any subtype of PPA at any time post-onset, irrespective of whether they were receiving treatment. Furthermore, studies that encompassed patients’ spouses or other relevant communication partners (e.g., health professionals) were also included in the review. Conversely, studies in which participants exhibited post-stroke aphasia or aphasia subsequent to brain injury were excluded, as were studies in which the participants’ type of aphasia was not specified.
Concept
This review encompasses studies that investigate the use and/or training of communication strategies amongst pwPPA and their significant communication partners. The authors employed the definition proposed by Simmons-Mackie and Damico (Simmons-Mackie & Damico, 1997), which defines a communication strategy as a novel or expanded communicative behaviour, whether spontaneously acquired or repeatedly employed, that is used to overcome a communication barrier, in order to meet transactional and interactional communicative needs.
The studies of interest comprised an array of communication strategies, encompassing both verbal and non-verbal modalities. The objective of the reviewers was to identify a comprehensive range of communication strategies that are part of the everyday lives of PPA individuals and those which are employed by conversation partners in dyadic or group conversations.
Context
The scoping review included studies from a range of countries, without imposing any geographical limitations for exclusion purposes. Furthermore, international studies conducted in a diverse array of settings were included for review, including healthcare facilities (such as primary care, hospital-based, and private practice settings), academic institutions (such as university departments), and community-based organizations. The studies included in the review were permitted to report data collected in person or in other ways, including through video conferencing.
Types of Sources
To ensure the quality and rigour of the sources included in this scoping review, only articles in their full version, published in peer-reviewed and indexed journals, were accepted. In addition, books, book chapters and theses were included in the review, while conference proceedings, opinion pieces and commentaries were excluded. Although studies conducted in disparate countries were accepted for consideration, only those written in English were accepted.
Only studies published from 2001 onwards were considered, as the evidence-based diagnostic criteria for PPA were established by Mesulam (Mesulam, 2001), thereby facilitating a common terminology within the scientific community.
Selected studies could employ a variety of study designs, including quantitative, qualitative, or combined designs. In addition to experimental study designs, quasi-experimental study designs were also considered in this scoping review. These included randomized controlled trials, non-randomized controlled trials, before-after studies, case series and single-case studies. Moreover, observational studies, including prospective and retrospective cohort studies, case-control studies, cross-sectional studies, and descriptive studies, were also included. Secondary literature, including reviews of any kind (e.g., systematic reviews, scoping reviews, narrative reviews), was also considered.
Search Strategy
An initial limited search was conducted in two different databases: Medline and Web of Science. Grounded in documented authors expertise in writing about PPA and their prior experience conducting narrative and systematic reviews (Cadório et al., 2017, 2019), along with the results of the initial pilot search, keywords were established to perform a new search on the selected databases. A systematic search of the aphasia literature included the following databases: PubMed, Scopus, Medline, LILACS, Web of Science, PsychINFO, Educational Resources Information Center (ERIC) and Portuguese National Open Access Scientific Repository (RCAAP). Accordingly, the advanced search was conducted in accordance with the specific conventions of the respective database, including the mapping and utilization of multiple search fields and filters. The search was constructed using Medical Subject Headings (MeSH), which were selected with great care to serve the specific purposes of this study. A comprehensive controlled vocabulary enabled the retrieval of relevant literature, including journal articles, theses, books and/or book chapters in the life sciences, particularly in the field of communication disorders resulting from neurodegenerative conditions. The search strategy entailed the utilization of keywords and index terms embedded within the titles and abstracts of pertinent articles. The following query was implemented: [(‘primary progressive aphasia’ OR ‘semantic dementia’ OR ‘non-fluent progressive aphasia’ OR ‘logopenic aphasia’ OR ‘progressive language’ OR ’language variant FTD’)] AND [(‘communication strategies’ OR ‘communication strategy’ OR ‘communication strategies’ OR ‘communication strategy’ OR ‘compensatory strategies’)].
Following the completion of the advanced search, the reference lists of the articles included in the review were examined to inform the subsequent search strategy.
Selection of Studies
All records retrieved from the selected databases were imported into Mendeley Reference Manager V1.19.8, and any duplicates were removed. Subsequently, the title and abstracts were evaluated independently by the authors in accordance with the established eligibility criteria. At this juncture, studies were excluded if the year of publication was prior to 2001, if the study only reported a research protocol, or if communication strategies used in PPA were not described in detail. Studies were also excluded, if it was not clear what type of aphasia participants had, if the participants exhibited post-stroke aphasia or aphasia following acquired brain injury. Then, the full text studies were subjected to independent analysis in accordance with the pre-established eligibility criteria, and the reference lists were consulted for additional information. Studies were excluded if they did not comply with the established PCC criteria. The reasons for exclusion are detailed in Appendix 1. To evaluate the reliability of the selected studies, inter-rater agreement was calculated, resulting in a value of 92%. The studies that were the subject of disagreement were discussed by the reviewers and a resolution was reached. A consensus was reached regarding the studies that were ultimately included in the review.
Data Extraction and Synthesis
The first and second authors developed a data extraction tool through which information deemed pertinent to the review was documented. The data entries encompassed the following information: (1) information about the study - (i) authors and year of publication, (ii) study location, (iii) type of study, (iv) sample size; (v) aim of the study; (2) information about participants - (vi) individuals’ diagnosis; and (3) information about the results - (vii) communication strategies used and/or trained, (viii) study outcomes. The authors created the data extraction tool in alignment with the JBI recommendations for scoping reviews (Peters et al., 2024). In instances where data was lacking or supplementary information was required, the authors of the studies were contacted to request the necessary data.
Data Analysis and Presentation
Two separate reviewers undertook independent analysis of the selected studies. The results of the data extraction were summarized and presented in tables and figures, thus facilitating reading. Furthermore, a narrative summary of the results was provided to respond to the research question: what communication strategies are employed and/or taught in the context of PPA?
Results
Search Results
A search of the databases was conducted between February and May of 2024, yielding a total of 269 citations. Of these, 9 were found in PubMed, 221 in Scopus, 1 in Web of Science, 3 in Medline, 1 in LILACS, 0 in PsychINFO, 24 in ERIC, and 10 in RCAAP. A further two records were identified through searches of grey literature. Following the removal of duplicates, 254 records remained. During the screening phase, a further 225 studies were excluded. Following a full-text eligibility check of the remaining 29 articles, three further studies were excluded. Thus, 26 studies qualified for inclusion in this review. The results of the search conducted for this review are presented in Figure 1, in the form of a PRISMA diagram (Tricco et al., 2018). Prisma Flow Diagram of the Scoping Review Process
Of the 26 studies deemed eligible for inclusion, 10 were non-experimental, while the remaining 16 were experimental. The non-experimental studies were comprised of eight reviews and two overviews. In contrast, the experimental studies comprised seven case reports, three case series, four comparison-group studies and two randomized controlled trials. Regarding the experimental studies, one was conducted in Brazil, one in Portugal, ten in the United States of America (USA), one in Canada, four in the United Kingdom (UK), and two in Australia.
Participants Characteristics
The participants included in the experimental studies were diagnosed with PPA (N = 138), svPPA (N = 12), nfvPPA (N = 18), lvPAA (N = 16), mixed PPA (N = 4), Alzheimer’s disease (N = 30), mild cognitive impairment (N = 1), Communication Partners (CPs) (N = 147), and healthy controls (N = 10). Most participants were diagnosed with PPA, without a specified subtype. The mean sample size across experimental studies was 20 participants per study. The experimental studies included a total of 386 participants, comprising 67 females and 49 males, with a mean age of 67.7 years. Four studies did not provide information regarding the sex of the individuals, and three studies failed to include data on the age of the participants. The non-experimental studies encompassed pwPPA, classical Alzheimer’s disease, neurocognitive disorders, and frontotemporal dementia.
Communication Strategies
The review identified a wide range of strategies that can be employed to facilitate effective communication between pwPPA and CPs. The authors have categorized the strategies into four distinct groups: verbal communication strategies, non-verbal communication strategies (Beeke et al., 2015; Hux et al., 2008; Sandt-Koenderman, 2004; Wilkinson et al., 2011), environmental modification strategies (Hinshelwood et al., 2016) and partner adaptation strategies (Fried-Oken et al., 2015).
Verbal communication strategies may be classified in a hierarchical manner, with the least assistive strategies positioned at one end of the spectrum, serving individuals with less severe impairments, and the most assistive strategies at the other end, serving individuals with more severe impairments. Examples of verbal communication strategies used in mild PPA are e-mail (Davies & Howe, 2019; Mooney et al., 2022), using an alternative word when the target word is not available, giving additional information around a person’s identity when unable to generate the name (Volkmer, Walton, et al., 2023), using self-cueing strategies to improve word access (semantic, orthographic or phonological) (Grasso et al., 2019), using voice recognition technology to write (Rogalski & Khayum, 2018), requesting assistance from the partner for specific information or lexical retrieval (Taylor et al., 2014). Conversely, the following represent illustrative examples of the verbal strategies deployed in cases of severe PPA: the use of the term “thing” when the target word is not available (Douglas, 2021), the use of a communication wallet (Mooney, Beale, et al., 2018; Rogalski & Khayum, 2018), the use of yes/no eye blinks (Fried-Oken et al., 2015), the use of remnants (e.g., theatre programmes, ticket stubs) (Mooney, Beale, et al., 2018), and the use of a “daily schedule” index card or a PPA card (Rogalski & Khayum, 2018).
In mild PPA, where cognitive abilities are relatively preserved, the use of non-verbal strategies can also facilitate communication. These may include the use of smartphone applications (e.g., Pic Collage) (Rogalski & Khayum, 2018; Volkmer et al., 2020), rate and rhythm control (Beber et al., 2018), intonation (Volkmer, Walton, et al., 2023), the use of a picture visual aid (Rogalski & Khayum, 2018), and in the case of stuttering in nfvPPA, repositioning the lips and tongue (Douglas, 2021). In cases of severe PPA, non-verbal strategies may include gesturing (Dial & Henry, 2023; El-Wahsh et al., 2021; Fried-Oken et al., 2015; Jokel & Meltzer, 2017; Mooney et al., 2022; Rebstock & Wallace, 2018; Volkmer et al., 2020), pointing (Kindell et al., 2013; Volkmer, Mistry, et al., 2023), and direct, face-to-face attention (Cycyk & Wright, 2008). Additionally, individuals may benefit from sitting near those who engage in excessive verbalization, as this can help to mitigate the effects of language-led fatigue (Davies & Howe, 2019). The use of a signal to mark the end of a turn (Volkmer, Walton, et al., 2023) is another possible strategy. The enactment may be regarded as a verbal (the utilization of direct reported speech) or non-verbal (the deployment of prosody and body movements) strategy and is similarly pertinent in both naturally developed and formally trained contexts (Davies & Howe, 2019; Kindell et al., 2013; Volkmer et al., 2021; Volkmer, Mistry, et al. 2023).
Partner adaptation strategies encompass a range of techniques, from topic orientation (Cycyk & Wright, 2008; Volkmer, Walton, et al., 2023) to positive reinforcement (El-Wahsh et al., 2021), partner-assisted scanning (Fried-Oken et al., 2015), and the modification of question structures using single-question prompts rather than dichotomous options (Cycyk & Wright, 2008). Additionally, these strategies entail providing pwPPA with ample time to express themselves (Dial & Henry, 2023; El-Wahsh et al., 2021; Volkmer et al., 2021), repeating information back to the PPA subject with elaboration (Taylor et al., 2014), and offering options to ascertain the target word (Volkmer, Mistry, et al., 2023). Further examples of partner adaptation strategies can be found in Table 2.
The environmental modification strategies that have been identified in the included studies are the establishment of simple alerting systems, the minimization of distractions, the provision of sticky notes, and the placement of communication aids in functionally appropriate locations, amongst others.
It is important to note that some of the aforementioned strategies are employed by the individual with PPA, while others are utilized by their partner, caregiver or family member.
Deatiled Description of the Verbal and Non-verbal Commucation Strategies Used in PPA
Deatiled Description of the Partner Adaptation Strategies and Environmental Modification Strategies Used in PPA
Effectiveness of Communication Strategies
Effectiveness of Communication Strategies in PPA
Research studies reporting communication strategies employed by individuals living with PPA have emphasized the significance of semantic cueing in prompting word retrieval during conversations in their early stages (Cycyk & Wright, 2008). Furthermore, the employment of assistive augmented communication strategies by people living with PPA and their respective partners has been shown to facilitate effective communicative interactions (Fried-Oken et al., 2015) that become multimodal (Mooney, Bedrick, et al., 2018; Volkmer, Mistry, et al., 2023), as well as independence in ADLs (Volkmer et al., 2020) and, consequently, overall quality of life. The low-tech AAC to which reference is made in the included studies is: (i) the utilization of memory books or written reminders (Lanzi et al., 2017); (ii) emphasizing keywords (Jokel & Meltzer, 2017; Volkmer, Walton, et al., 2023); (iii) writing graphemes, keywords and messages (Fried-Oken et al., 2015; Jokel & Meltzer, 2017; Mooney et al., 2022; Roberts et al., 2022; Volkmer, Walton, et al., 2023); (iv) drawing (Fried-Oken et al., 2015; Jokel & Meltzer, 2017; Mooney et al., 2022; Rebstock & Wallace, 2018; Volkmer, Walton, et al., 2023); (v) using signage (Lanzi et al., 2017); (vi) using gestures, facial expressions, enactment (Jokel et al., 2017; Mooney et al., 2022; Volkmer et al., 2021; Volkmer, Mistry, et al, 2023); (vii) using written reminders (Lanzi et al., 2017); (viii) using a calendar and/or a planner (Lanzi et al., 2017); (ix) using a notepad and/or notebook (Lanzi et al., 2017); (x) using written cues combined with picture cues (Lanzi et al., 2017). It has been demonstrated that, particularly, the employment of gesture and enactment are successful coping mechanisms for anomia in functional communication (Davies & Howe, 2019; Volkmer et al., 2021). In addition, the high-tech AAC reported in the records includes the use of applications such as CoChat (Mooney, Bedrick, et al., 2018). The findings of the retrieved studies indicate that the effective use of AAC requires adequate training directed towards both pwPPA and CPs (Fried-Oken et al., 2012). Multimodal turn-construction practices, which also require training, facilitate the co-construction of narratives (Volkmer, Mistry, et al., 2023).
In svPPA, enactment was found to be a good way of establishing functional communication (Davies & Howe, 2019; Kindell et al., 2013) and email helped svPPA individuals to maintain contact with family and friends. Email allowed svPPA to take the time they needed to process the information they were receiving or giving (Davies & Howe, 2019).
In nfvPPA, dysfluency appears to be minimized by repositioning the lips and tongue to the opposite oral position to that intended (Douglas, 2021). Individuals with co-occurring apraxia of speech appear to benefit from rate and rhythm control techniques (Beber et al., 2018) and the use of AAC devices (Nickels & Croot, 2014). The quality and length of communicative exchanges seem to improve with the use of hand gestures and phonological cueing (Cadório, Figueiredo, Martins, Cardoso, et al., 2019; Douglas, 2021). In these patients, fatigue and overstimulation may be avoided by allowing periods of silence before significant conversations and/or limiting the amount of conversation people with nfvPPA engage in (Douglas, 2021). In contrast, semantic cueing and word-finding exercises seem to play an irrelevant role in nfvPPA (Cadório, Figueiredo, Martins, Cardoso, et al., 2019; Douglas, 2021).
In lvPPA, the use of semantic and orthographic/phonemic self-cueing strategies did not improve word retrieval (Grasso et al., 2019).
Other communication strategies have proved less effective. For example, adaptative mechanisms used by family members, such as multiple questions or test questions. These seem to cause frustration and feelings of incompetence in pwPPA (Volkmer et al., 2021). In addition, gestures and drawing are not recommended if the aim is to facilitate word retrieval or change of communication modality (Rebstock & Wallace, 2018). The use of speech-generating devices (e.g., Lightwriter, GoTalk Express 32, Lingraphica) does not support conversational exchanges (Mooney et al., 2022), nor does any other AAC device without formal training (Fried-Oken et al., 2012).
Summary of the Data Extracted From the Full-Text Analysis
Discussion
The implementation of strategies and approaches designed to optimize communication is of great relevance to pwPPA, who experience a detriment to their quality of life as they lose their premorbid speech level of function (Douglas, 2021). However, there is a dearth of information regarding which strategies facilitate effective communication in PPA in comparison with post-stroke aphasia. In contrast to post-stroke aphasia, which has been characterized by a more stable presentation, PPA is recognized as a progressive condition. Consequently, there has been an ongoing attempt to review, devise, and implement appropriately targeted strategies and adaptations when difficulties with speaking, reading, or writing arise (Douglas, 2021). The aim of this review was to identify the communication strategies employed and/or trained in PPA and to ascertain their value to functional communication.
The key to assisting pwPPA in dealing with the challenges they face daily is to teach CPs meaningful skills and strategies to improve communication (Burgio et al., 2001; O’Rourke et al., 2018). In communicative interactions, the literature shows that partner assistance is more helpful than prompting or cueing (Taylor et al., 2014). CPs might acquire the ability to utilize communication strategies through formal instruction. Said instruction may include such activities as collaborative problem-solving, role-playing, strategy practice activities with performance feedback, and conjoined reflections, in addition to other therapeutic activities (Roberts et al., 2022). In this regard, Volkmer and colleagues (Volkmer et al., 2020) state that speech-language therapy should provide CPs training to maximize opportunities to build on, reinforce and generalize existing communication strategies in a relevant context. The delivery of CPs’ training is typically conducted by the speech and language therapist or pathologist. The ‘Better Conversations with Primary Progressive Aphasia’ (BCPPA) programme, for example, has been developed to facilitate improved communication in pwPPA and respective CPs. The programme was designed to reduce barriers to conversation and increase facilitators to conversation through the use of participant’s pre-intervention video-recorded conversation samples, to provide clips for video feedback during intervention sessions (Hoffmann et al., 2014).
Similar to the evidence from post-stroke aphasia, building on existing communication skills may be a more effective way of compensating for communication deficits than learning new strategies (Volkmer et al., 2020). In the process of selecting strategies or techniques, it is imperative to consider the preserved language abilities of pwPPA. These include phonological and autobiographical memory processes in svPPA, and semantic memory abilities in nfPPA and lvPPA (Cadório, Figueiredo, Martins, & Lousada, 2019; Croot, 2018). To leverage patients’ strengths, it is recommended that a variety of communication modalities be employed (Fried-Oken et al., 2015). The integration of AAC through assistive tools, environmental adaptations, and behavioural modifications is more readily embraced when CPs are engaged from the initial stages of the disease. Multimodal communication aids, when scaffolded by CPs, appear to complement both receptive and expressive language skills, thereby increasing communicative effectiveness (King & Simmons-Mackie, 2017), increasing social participation and improving decision making (May et al., 2019; Rebstock & Wallace, 2018). It is important to note that strategies may be subject to modification over time to achieve positive outcomes in the face of gradual deterioration in language ability (Fried-Oken et al., 2015).
A communication-supportive environment helps a person know what to expect, encourages appropriate and functional behaviours, uses multiple modalities to educate, and minimizes distracting stimuli (Brush et al., 2012).
Conclusion
In PPA, person-centered, functional goals should focus on developing automatic, efficient use of communication strategies that avoid cognitive burden on the individuals diagnosed with PPA and their CPs.
Training CPs is as important as creating an environment for optimal communication (e.g., turning off the TV during conversations, placing communication aids in functionally relevant locations, making sticky notes available). Often, individuals diagnosed with PPA and their immediate social circle have already developed their own strategies for everyday conversations. In such cases, the speech and language therapist’s role is to identify which strategies are working well, to encourage the continued use of these strategies, to support generalization of these strategies to personally relevant settings, to identify communication patterns that may act as barriers, to offer additional strategies in anticipation of impending decline, and to adjust the use of strategies within the course of the disease (Rogalski & Khayum, 2018).
This scoping review shows that PPA population use verbal and non-verbal communication strategies, environmental communication strategies and partner adaptation strategies to facilitate successful communication. To summarize, the employment of assistive augmented communication strategies, comprising both low-tech and high-tech AAC, appears to enhance communication effectiveness. This is attributable to the utilization of multimodal resources, which aid in compensating for progressive language decline.
Future research should investigate which strategies better serve the patients’ needs at each time point, taking into consideration the PPA subtype.
Supplemental Material
Supplemental Material - Communication Strategies Used in Primary Progressive Aphasia: A Scoping Review
Supplemental Material for Communication Strategies Used in Primary Progressive Aphasia: A Scoping Review by Inês Cadório and Daniela Vieira in Dementia
Footnotes
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Supplemental Material
Supplemental material for this article is available online.