Conversational coherence: discourse analysis

of older adults with and without dementia

Katinka Dijkstraa,*, Michelle S. Bourgeoisb, Rebecca S. Allenc,Louis D. Burgioc

aDepartment of Psychology, Florida State University, Tallahassee, FL 32306-1270, USAbDepartment of Communication Disorders, Florida State University, Tallahassee, FL 32306-1200, USA

cCenter for Mental Health and Aging, The University of Alabama, Tuscaloosa, AL 35487-0315, USA

Received 6 February 2003; received in revised form 28 May 2003; accepted 15 June 2003

Abstract

The purpose of this study was to compare the discourse profiles of 30 nursing home residents with

dementia and of 30 healthy older adults. A total of 60 transcripts of interview style conversations

were analyzed using a discourse analysis schema. The results revealed a higher frequency of

discourse building features, such as coherence and cohesion, for healthy adults compared to adults

with dementia. Conversely, discourse-impairing features, such as disruptive topic shifts and empty

phrases, were found more often in conversations of adults with dementia compared to healthy adults.

Conversational partners deviated from their conversation protocol when talking to adults with

dementia by including facilitative strategies in the conversation. Discourse features in interview

style conversations in adults with dementia reflect declines in their memory.

q 2003 Elsevier Ltd. All rights reserved.

Keywords: Discourse; Dementia; Conversation; Coherence; Nursing home; Memory

Much research has explored discourse impairments in persons with dementia. Most

persons with dementia have limited vocabulary, frequent word finding problems

(Kempler, 1991), and breakdowns in topic maintenance and coherence (Bayles, 1985)

in contrast to healthy adults whose discourse is relatively intact. The occurrence of these

deficits depends on the type of dementia, as well as the course and stage of the disease,

with a relative absence of certain discourse deficits, such as empty phrases, in the early

stages of Alzheimer’s disease (Dijkstra, Bourgeois, Petrie, Burgio, & Allen-Burge, 2002).

0911-6044/$ - see front matter q 2003 Elsevier Ltd. All rights reserved.

doi:10.1016/S0911-6044(03)00048-4

Journal of Neurolinguistics 17 (2004) 263–283

www.elsevier.com/locate/jneuroling

* Corresponding author.

E-mail address: dijkstra@psy.fsu.edu (K. Dijkstra).

These discourse deficits reflect impairments in cognitive functioning that are characteristic

of dementia, such as deficits in semantic memory (Orange & Purves, 1996) and reductions

in working memory capacity (Waters, Caplan, & Rochon, 1995).

The literature on discourse in dementia has been comprised of studies with small

samples, different types of discourse tasks, and hardly any linkage to a theoretical

framework. Most studies have identified discourse deficits in patients with mid-stage

dementia during non-conversational tasks, such as picture naming (Hier, Hagenlocker, &

Schindler, 1985; Tomoeda, Bayles, Trosset, Azuma, & McGeagh, 1996). To gain a deeper

understanding of the relationship between memory deficits and discourse, however, more

detailed analyses of the discourse of persons in naturalistic situations, such as

conversations, are needed. To date, there have been no analyses of specific discourse

features that might reveal the discourse building features or the discourse deficits in

conversations of persons with dementia. It is possible that certain patterns of discourse

building features, such as features contributing to the continuation of discourse, as well as

discourse impairing features, such as features hindering the continuation of discourse,

would be characteristic of cognitive impairment. This knowledge would be useful to

caregivers and clinicians who are interested in modifying their own conversational style to

support and maintain satisfying interactions with persons with dementia as their disease

progresses. In addition, past studies have failed to compare any discourse characteristics of

the conversational partners of persons with and without dementia. Information about how

partners use discourse differently when conversing with persons of different cognitive

status could guide the design of education and training protocols to facilitate

conversational interactions with persons with dementia.

This study examined patterns of discourse building and discourse impairing features in

conversations between conversational partners and healthy older adults and adults with

dementia. This was done with an elaborate discourse analysis schema that captured

building elements of discourse, such as cohesion, coherence, and conciseness (Cherney,

Shadden, & Coelho, 1998; Dijkstra, Bourgeois, Petrie, Burgio, & Allen, 2002) in addition

to discourse impairments. The purpose was to produce a detailed description of discourse

elements that are characteristic of naturalistic discourse of persons with dementia and to

relate these elements to memory processes.

1. Discourse features

There are a variety of discourse types, including descriptive, narrative, procedural,

persuasive, expository, and conversational discourse (Cherney, 1998). An analysis of

discourse performance within a certain type of discourse, such as conversations, in a

specific clinical population, such as persons with Alzheimer’s disease or non-stroke

related dementia, can provide important information as to how their linguistic abilities are

affected. The analysis of such discourse involves procedures that identify the underlying

cognitive and linguistic processes that contribute to discourse impairment (Cherney,

1998).

Discourse performance in conversations can be described as supportive, or ‘discourse

building’, when it contributes to the continuation of the conversation. Discourse

K. Dijkstra et al. / Journal of Neurolinguistics 17 (2004) 263–283264

performance can also hinder the communicative purpose of the conversation, making it

harder for the conversational partner to understand what the other person means. These

elements of discourse are called ‘discourse impairing’ features. Cohesion, coherence, and

conciseness can be considered discourse building features, whereas revisions, aborted

phrases, empty phrases, repetitions, indefinite words and disruptive topic shifts can be

considered discourse impairing features under most naturalistic conditions (Dijkstra et al.,

2002).

To some extent, discourse building and discourse impairing features can be seen as

counterparts on a continuum of discourse features. At one end of the continuum, errors in

discourse performance, such as incorrect use of pronouns or referents or indefinite words,

can be considered to hinder the continuation of the conversation. At the other end of the

continuum, the correct use of pronouns, verb tense, or the occurrence of unique words can

be considered to contribute to the continuation of conversation. Certain discourse features,

such as topic maintenance, elaborations on a certain topic, and disruptive topic shifts

(Coelho, 1998), may be considered as containing both discourse building and impairing

components.

Cohesion has been defined in terms of surface indicators of relations within and

between sentences. Cohesion occurs when the interpretation of an element in the discourse

is dependent on that of another element (Halliday & Hassan, 1976; Ripich, Carpenter, &

Ziol, 2000). Cohesive ties are the elements that conjoin these elements in the form of

references, substitutions, ellipsis, conjunctions, and lexical markers (Liles & Coelho,

1998). References relate to objects or persons mentioned in a preceding or following text

(Ripich et al., 2000). A subtype would be pronominal reference, or referential cohesion,

which refers to the correct use of pronouns (Dijkstra et al., 2002). Conjunctions, such as

‘and’, ‘so’, or ‘but’, or causal cohesion are an indication of the systemic relationships

between sentences (Ripich et al., 2000). Temporal cohesion reflects correct use of verb

tense (Dijkstra et al., 2002; Liles & Coelho, 1998).

Coherence is another example of a discourse-building feature. It has been mostly

described as the result of appropriate topic maintenance in discourse (Hakala & O’Brien,

1995; Laine, Laakso, Vuorinen, & Rinne, 1998; McNamara and Kintsch, 1996; Albrecht

& O’Brien, 1995; Ulatowska & Chapman, 1991). Coherence can be defined locally as an

indication of how closely an utterance (sentence) is related in topic and content to the

immediately preceding utterance, or globally as an indication of how closely an utterance

is related to the general topic (Laine et al., 1998). Global and local coherence presumably

are represented differently in a person’s discourse. Local coherence incorporates new

information with immediately preceding information at the utterance level and global

coherence represents thematically higher order structures of discourse (Hakala & O’Brien,

1995; McNamara & Kintsch, 1996).

Conciseness, another discourse building category, is the component of adding

information without redundancy. It is an indicator of high information content, the

quality of information content, the efficiency of information (Shadden, 1998b), and the

relevance of discourse (Ripich & Terrell, 1988; Shadden, 1998b; Tomoeda et al., 1996). A

lack of conciseness is represented as verbosity, or the addition of redundant, irrelevant,

incorrect or off-topic information. A lack of conciseness by one conversation partner

makes it difficult for the other conversation partner to respond because of limited

K. Dijkstra et al. / Journal of Neurolinguistics 17 (2004) 263–283 265

information conveyed. In most cases, conciseness is established by comparing an a priori

list of words with responses on a picture description or a procedural description task

(Shadden, 1998b). However, conciseness can also be established in a conversational

interview format (Ripich & Terrell, 1988).

Discourse impairing categories hinder the continuation of conversation through errors,

vagueness and incompleteness demonstrated through aborted phrases, empty phrases

(phrases that have no meaning), repetitions, indefinite terms (words that are non-specific,

such as ‘thing’ and ‘stuff’) and disruptive topic shifts (Garcia & Joanette, 1997).

Repetitions in the context of discourse impairing features have been described as

inappropriate restatements of ideas in a picture description task (Tomoeda et al., 1996;

Ulatowska & Chapman, 1991), or complete repetitions of words in conversations

(Bourgeois, Dijkstra, Burgio, & Allen-Burge, 2001). Repetitions occur relatively

frequently in the discourse of persons with Alzheimer’s disease (Bayles & Tomoeda,

1991). Disruptive topic shifts are tangents or digressions from topic (Ulatowska &

Chapman, 1991). Comparisons of the discourse of healthy older adults and older adults

with dementia indicated a higher frequency of empty and indefinite words, and aborted

phrases in the group with dementia (Hier et al., 1985; Ripich & Terrell, 1988; Kempler,

1995). Moreover, the use of pronouns by persons with Alzheimer’s disease is often

inappropriate (Ulatowska, Allard, & Donnell, 1988; Kempler, 1995). The proper use of

pronouns requires that the information conveyed in the pronoun matches with information

earlier in discourse; therefore, sufficient memory capacity is required to maintain active

mental representation of previously mentioned referents (Kempler, Almor, MacDonald, &

Anderson, 1999). This memory capacity and the representation of vocabulary in semantic

memory are assumed to be impaired in persons with dementia (Baddeley, 1996; Orange &

Purves, 1996).

2. Discourse and memory

Three memory functions are relevant in discourse production and comprehension in

adults with dementia: semantic memory, episodic memory, and working memory.

Episodic memory refers to memory of events (Tulving, 1983) and has been found to be

impaired in adults with dementia (Dijkstra, 2001; Fromholt & Larsen, 1991; Souchay,

Isingrini, & Gil, 2002). Since an analysis of episodic memory deficits in conversations

would necessitate a content analysis rather than a linguistic analysis of the conversation,

this analysis does not fall within the scope of our study.

Semantic memory consists of highly overlearned general knowledge and vocabulary

(Tulving, 1983). It is a widespread assumption that discourse impairments reflect deficits

in semantic memory (Orange & Purves, 1996; Salmon, Heindel, & Butters, 1991).

Although receptive and expressive verbal abilities and vocabulary seem to remain

preserved in healthy older adults until they are in their mid seventies (Schaie, 1996),

research has shown evidence of age-related decrements for certain aspects of semantic

memory, such as word-finding failures, in particular retrieving names, in healthy older

adults (Bayles, Tomoeda & Trosset, 1990; Kempler, Andersen, & Henderson, 1995).

These specific impairments appear to be prevalent in persons with dementia (Kempler,

K. Dijkstra et al. / Journal of Neurolinguistics 17 (2004) 263–283266

1991; Shadden, 1998a,b). In particular, semantic memory deficits appeared to explain

retrieval failures that resulted in aborted phrases, empty words, revisions, and referential

errors in persons with AD when performing a picture description task (Hier et al., 1985;

Tomoeda et al., 1996). These types of retrieval failures also occur in the conversations of

persons with dementia (Hier et al., 1985; Kempler et al., 1991; Liles & Coelho, 1998;

Tomoeda et al., 1996). Performance on other semantic memory tasks, such as object and

picture naming tasks (Knotek, Bayles, & Kaszniak, 1990) was significantly lower among

persons with AD compared to healthy controls (Hier et al., 1985; Nicholas, Obler, Albert,

& Helm-Estabrooks, 1985; Tomoeda & Bayles, 1993; Tomoeda et al., 1996).

Another memory component that is affected in persons with Alzheimer’s disease is

working memory capacity (Baddeley, 1996; Della Salla, Logie, & Spinnler, 1992; Orange

& Purves, 1996). Working memory requires the availability of cognitive resources to

process incoming information or previously stored information, and to store new

information (Baddeley, 1986, 1996). Research has revealed that persons with Alzheimer’s

disease have shorter immediate memory spans (Almor, Kempler, MacDonald, Andersen,

& Tyler, 1999; Baddeley et al., 1986; Baddeley, 1996; Baddeley, Della Salla, & Spinnler,

1991; Della Salla et al., 1992) and deficits in performance on verbal working memory

tasks (Spinnler et al., 1988).

The capacity theory provides an explanation of the consequences of high task demands

on a person’s capacity to perform a comprehension task that is meaningful for predicting

occurrence of certain discourse features in healthy and cognitively impaired populations

(Just & Carpenter, 1992; Just, Carpenter, & Keller, 1996; Miyake, Carpenter, & Just,

1994). According to the capacity theory, storage and computation functions in working

memory compete with each other for limited cognitive resources under conditions of high

demand on these resources. When the resource pool is about to be exceeded, a de-

allocation process occurs that limits processing and storage functions (Miyake et al.,

1994). Under these conditions, persons will favor processes that are less demanding (i.e.

less complex or requiring less attention) over those that are more demanding of their

cognitive resources. In other words, differential performance among persons with different

working memory capacity, such as adults with and without some cognitive impairment,

would occur in cases of high demand and reflect an implicit allocation policy that includes

a shift of available resources to less demanding processes. According to Just and Carpenter

(1992), this would be particularly true for interactive processes that are assumed to be

subject to capacity constraints. Another assumption is that changes in capacity play a role

in task performance when differences in performance can be interpreted as the result of

changes in age and concentration ability (Just & Carpenter, 1992).

Several studies on healthy older adults have provided support for some of the

assumptions stated in the capacity theory (Cohen, 1979; Kemper, 1986, 1988; Miyake

et al., 1994). Studies on adults with Alzheimer’s disease or other dementias demonstrated

relationships between working memory capacity and dementia severity (Croot, Hodges, &

Patterson, 1999; Della Salla et al., 1992; Kemper, 1997; White & Murphy, 1998).

Specifically, a study on reference comprehension impairments in persons with

Alzheimer’s disease demonstrated an overall decrease in their activation of referents,

which were the result of limitations in working memory that hindered the continued

K. Dijkstra et al. / Journal of Neurolinguistics 17 (2004) 263–283 267

activation of the representation of referents and the semantic features underlying the

referents (Almor et al., 1999).

The research discussed above provides support for the assumption that persons with

dementia have differential working memory capacity and semantic memory ability, and

therefore differential abilities to use discourse-building features in conversations. When

dealing with more complex processes in discourse production, that require continued

activation of topic information in a conversation, persons with dementia will have more

difficulty maintaining these discourse building features than healthy adults. If cognitive

resources are insufficient to adequately continue the conversation, then discourse

impairments are more likely to occur. A general prediction would be that healthy adults

are more capable of maintaining discourse-building features in their conversations than

adults with dementia, who may experience deficits in their access to semantic memory

stores. Further, adults with dementia may experience an overload of their cognitive

resources, which results in diminished ability to maintain discourse-building features and

increased frequency of discourse deficits relative to healthy older adults.

A conversation partner may help lower the demands on working memory capacity

when conversing with a person with dementia by avoiding the breakdown of

conversational coherence through the use of a facilitating context. For example, a

conversation partner who repeats a question (Lamar, Obler, Knoefel, & Albert, 1994;

Kemper, Ferrell, Harden, Finter-Urczyk, & Billington, 1998), repeats or paraphrases

information (Small, Kemper, & Lyons, 1997), opens up a memory book with personal

information about the person with dementia (Bourgeois et al., 2001), or uses cues when the

person with dementia gets stuck in the conversation (Dijkstra et al., 2002), may support

conversational coherence, cohesion, or conciseness of persons with dementia. Repetition

of information, the availability of information in a memory book, and the provision of cues

aids the activation or maintenance of topic information without adding cognitive demands

on the person with dementia. It can be expected that conversational partners would more

likely use facilitative strategies when discourse impairments occur, even if they are not

specifically instructed to do so.

To summarize, the extent to which discourse building elements and discourse

impairments occur in conversations of persons with dementia and in those without

dementia is not known. Nor is the relationship known between these discourse features,

memory functions, and facilitating contexts in persons with dementia. The goal of this

study was to explore the relationships between discourse features in language production,

memory function, and the conditions under which facilitation of language production

occurs.

The following hypotheses were tested, based on the general assumption that adults with

dementia would display different patterns of discourse building and discourse impairing

features in comparison to healthy older adults.

1. There will be more discourse building features and fewer discourse-impairing features

in the discourse of healthy adults compared to the discourse of persons with dementia.

2. Discourse of conversation partners will reflect higher use of facilitative strategies when

talking with persons with dementia than when talking with healthy controls.

K. Dijkstra et al. / Journal of Neurolinguistics 17 (2004) 263–283268

3. Method

3.1. Participants

Thirty healthy, community dwelling (22) or institutionalized (8) healthy older adults

without dementia, and 30 nursing home residents with dementia residing at seven nursing

homes in the Tallahassee area participated. They were involved in a larger intervention

study described elsewhere (Allen-Burge, Burgio, Bourgeois, Sims, & Nunnikhoven, 2001;

Bourgeois et al., 2001; Burgio et al., 2001). All participating nursing home residents were

diagnosed with non-stroke-related dementia or Alzheimer’s disease by their primary care

physician, on-site staff physician, or the neurologist of the local hospital. These diagnoses

were listed in their medical chart but did not include further details since they were

community-based diagnoses. Physicians did not diagnose residents using NINCDS-

ADRDA criteria. However, all patients with any evidence of stroke-related symptoms

were excluded from the sample. Other exclusionary criteria were: younger than 55 years of

age, a major hearing or visual impairment (assessed by the hearing/vision screening), a

history of DSM-III alcoholism or schizophrenia, a life expectancy of less than six months,

or a score of less than eight total points on an expressive language assessment (Bourgeois,

1992).

This assessment consisted of three different tasks: an oral reading task, a picture

description task, and a conversational sample. The reading assessment (Bourgeois, 1992)

measured the extent to which dementia patients were able to read aloud sentences with a

relevant illustration, such as ‘My sister’s name is Mary’. Every word read and pronounced

correctly yielded one point, with half points attributed to partly read and pronounced

words. For example, the sentence ‘I live in Swissvale’, read as ‘I live in Swissvalley’,

received 3.5 points. The picture description task was an assessment of semantic memory

(Knotek et al., 1990). The participant was asked to describe what was happening

in a picture from the Boston Diagnostic Aphasia Examination in a 2 min time span

(Goodglass & Kaplan, 1976). Verbal productions were analyzed for number of content

units (Yorkston & Beukelman, 1980). Repetitions or items that were not in the picture

were not counted. The conversation sample, a 5 min conversation between a research

assistant and the subject, was rated on a scale of 1–6 (from near muteness to fluent

conversation) (Bourgeois, 1992).

A cognitive screening assessment was conducted on all participants using the Mini

Mental State Exam (MMSE) (maximum score ¼ 30) (Folstein, Folstein, & McHugh,

1975). The healthy group had an average MMSE score of 28 (SD ¼ 2); the cognitively

impaired group had an average MMSE score of 14.2 (SD ¼ 6.5). Average age of

participants was 77.7 years (SD ¼ 8.3, healthy) and 80.2 years (SD ¼ 4.4, impaired).

They were mostly female (63%, healthy; 83%, impaired) and white (100%, healthy; 80%,

impaired). Their average education was 14.5 years (SD ¼ 3.3, healthy) and 13.9 years

(SD ¼ 2.6, impaired).

Independent sample t-tests were conducted to examine group differences due to age,

education, and cognitive impairment. No significant differences were found for age and

education ðt , 1:5Þ: The difference between healthy adults and adults with dementia for

MMSE was significant, tð52Þ ¼ 9:86; p , 0:001:

K. Dijkstra et al. / Journal of Neurolinguistics 17 (2004) 263–283 269

Conversation partners. Twenty-four nursing aides who were assigned to the residents

with dementia (22) or the institutionalized residents (8) participated as conversation

partner. Fifty percent were African–American, and 50% were Caucasian. Most of them

(95%) were female. Their average age was 35 years (SD ¼ 7.4) and average years of

education was 14 (SD ¼ 0.78). In addition, 4 experimenters (all white women, mean

age ¼ 25.9, SD ¼ 7.0) were conversation partners for the 22 healthy community dwelling

healthy adults. None of the conversation partners had received specific training on how to

communicate with adults with dementia. None of the conversations partners knew the

residents or participants well. Despite the fact that nursing aides knew residents with

whom they were going to have a conversation in the capacity of providing care, research

has established that the communicative environments in nursing homes are impoverished,

lacking social conversations between nursing home staff and residents (Lubinksi, 1995).

The four experimenters, undergraduate students doing a directed individual study, had not

met the older community dwelling participants until the conversation started. To minimize

potential interference of an existing relationship with the conversation partner, all

conversation partners had to adhere to a strict protocol, described below.

3.2. Procedure

Conversational samples. Conversations between the 60 participants and their

conversation partners were audiotaped and later transcribed verbatim for discourse

analysis purposes. Each conversation was a 5 min interview-style conversation (timed

with a countdown timer) between a participant and his or her conversation partner during

which the partner was instructed to prompt the participant to talk about his or her family,

life, and day. The conversation partner was instructed not to ask other questions than those

three and only to provide prompts such as ‘tell me more’, if the participant stopped talking.

These instructions were given verbally and the three topic prompts were also written on a

piece of paper that the conversation partner kept in view during the interview. These

procedures ensured that the overall structure of the interview style conversations was

consistent across the sample.

The transcripts were segmented into utterances following conventional sentence

boundaries and intonation contour by two coders using the transcript analysis procedures

of Lyons and colleagues (1994) and that of Cherney and colleagues (1998). Sentence

fragments, incomplete sentences, revisions of a previous utterance, and additions to the

previous utterance following a pause were considered as separate utterances. Lexical

fillers, such as ‘let us see’ were transcribed as separate utterances if they occurred at the

beginning or end of another utterance. If they occurred within an utterance, they were

transcribed as being part of that utterance.

The transcripts were then coded according to the discourse building and discourse

impairing features for persons with dementia and according to discourse features for

conversation partners (Dijkstra et al., 2002a). Table 1 illustrates the definitions for the

different features used by the person with dementia. Appendix A is a description of the

guidelines that were used for coding. The list of categories was compiled from a literature

review in the field of discourse in dementia (Cherney et al., 1998), and subsequently

organized under discourse building or discourse impairing features. Several categories that

K. Dijkstra et al. / Journal of Neurolinguistics 17 (2004) 263–283270

were included in other discourse analyses were not included in our analysis for lack of

occurrence. These categories were circumlocutions, paraphasias, ellipsis, substitutions,

and revisions (see Cherney et al. (1998), for a complete description). Discourse building

categories included the number of unique words, the number of information units,

conciseness, elaborations on topic, number of occurrences of global and local coherence,

referential, temporal and causal cohesion, and topic maintenance. Discourse impairments

included: the number of repetitions, empty phrases, indefinite terms, aborted phrases,

incorrect verb tense, incorrect referents and disruptive topic shifts.

Table 1

Discourse analysis schema for participant discourse (adapted from Dijkstra et al., 2002)

Categories and references Examples Frequency

Discourse building characteristics

Number of unique words (Hier et al., 1985) Well I was born.

I was born in 1924

6

Number of information units; relevant, truthful,

non-redundant utterances (Bayles and Tomoeda,

1991; Shadden, 1998b)

I went to school in

uh New Jersey. I did

1

Conciseness: information units/words (Hier et al.,

1985; Tomoeda et al., 1996)

I was born in 1916 1/5

Elaborations, number of elaborative utterances on

the topic of conversation (Shadden, 1998)

No, I went to grade

school first of course

And then high school

1

Global coherence; number of utterances that represent

the topic of conversation (Laine et al., 1998)

Well I was born and

raised in Ohio (topic is ‘life’)

1

Local coherence; number of utterances connected to

the preceding utterance (Laine et al., 1998)

Yeah, can you tell me about

your day? Well, uh, I start

getting ready to get up around

seven or something

1

Cohesion: number of utterances with: (Ulatowska and

Chapman, 1991)

a) Referential: correct pronominal reference My mother was a baroness

when she married my father

1

b) Causal: conjunctions So there I stayed till I was

almost 17 years old

2

Temporal: correct use of verb tense (Liles & Coelho, 1998)

Topic maintenance: elaborations divided by disruptive

topic shifts (Coelho, 1998)

It is a very nice place. Have

you met this lady?

1/1

Discourse impairments

Complete repetitions (Bayles et al., 1985; Hier et al., 1985) Just, just, just books. 2

Empty phrases; utterances with little or no content

(Nicholas et al., 1985)

First and then and that and

that was all

1

Indefinite terms; non specific words (Nicholas et al., 1985) There’s been a lot of good

things going on there

2

Aborted phrases, incomplete phrases not revised within

two succeeding sentences (Tomoeda et al., 1996)

Well I am supposed to have 1

Disruptive topic shifts, abrupt shift of topic (Garcia and

Joanette, 1994; Mentis et al., 1995)

And they are both with the

Lord You are a good-looking

woman

1

Incorrect pronominal referencing (Ulatowska and Chapman,

1991; Shadden, 1998)

And I was not always it, any idea? 1

K. Dijkstra et al. / Journal of Neurolinguistics 17 (2004) 263–283 271

Additionally, conversation partner discourse was analyzed for its facilitating,

questioning, or prompting nature (Bourgeois et al., 2001; Dijkstra et al., 2002). Questions

and prompts were considered as discourse-initiating behaviors; more specifically, prompts

were classified as instructed initiators, and questions as non-instructed initiators. These

conversation strategies elicited a response from the conversation partner without

necessarily facilitating the response. Prompts included the three topic prompts (Tell me

about your family/life/day) and subsequent general prompts to continue the conversation

(Tell me more). Facilitators were considered to be discourse responsive behaviors

(Dijkstra et al., 2002). The following facilitators were distinguished: repetitions that

repeated previously mentioned information, encouragements to keep talking, and cues to

help the speakers find a word in instances where they were stuck in the interview style

conversation. All facilitators had in common the potential to enhance the participant’s

ability to talk and contribute content to the conversation. The categories are listed in

Table 2. To illustrate the application of the discourse schema, three excerpts of coded

interview style conversations are included in Appendix B.

3.3. Reliability

Two independent raters coded discourse building and impairing features in the

transcripts. An item-by-item comparison of coding agreement was calculated for all

discourse categories in 20% of the transcripts. Cronbach’s alpha for resident codes was .91

(SD ¼ 0.10), ranging from 0.71 to 1.0. Cronbach’s alpha for conversation partner codes

was .94 (SD ¼ 0.05), ranging from 0.88 to 0.99.

4. Results

4.1. Participant discourse

To control for differences in the amount of talking in the five-minute period, proportion

scores were calculated for each variable (instances of discourse building and discourse

Table 2

Discourse analysis schema for conversation partner discourse

Categories and references Examples

Total number of questions Anything else you can tell me about?

Total number of prompts Tell me about your day (life, family)

Facilitators

Repetitions: repeating utterance R: She works all the time.

A: She works all the time.

Encouragements: keep conversation going R: I had a ** on my shoulder.

A: Ok, That’s good.

Cues: provide missing information R: And uh, and uh, and with a…

A: Keyboard.

R: Yeah.

Note: A, nursing aide; R, resident.

K. Dijkstra et al. / Journal of Neurolinguistics 17 (2004) 263–283272

impairing features divided by the total number of participant utterances in the participant

categories; instances of prompts, questions, and facilitators divided by the total number of

conversation partner utterances in the conversation partner categories). Conciseness was

calculated as the number of information units from participants divided by the number of

words from the participants.

The first hypothesis predicted a greater occurrence of discourse building elements and

fewer discourse impairing features in the discourse of healthy adults, compared to

discourse of persons with dementia. Table 3 displays the means and standard deviations

for the resident discourse characteristics for healthy and cognitively impaired participants

respectively. Independent sample t-tests were conducted to assess whether the healthy and

impaired group differed from each other significantly on discourse building and discourse

impairing categories. Because of the large number of tests conducted, preset alpha level of

,0.05 was set at 0.005 for the 10 t-tests concerning discourse building features, at 0.0083

for the six tests concerning discourse impairing features, and at 0.01 for the five tests

concerning conversation partner characteristics.

Most of the discourse building elements, and all of the discourse impairing categories

demonstrated some degree of statistically significant difference between the groups

according to the t-tests. Differences between healthy adults and adults with dementia in

discourse building features were found with regard to the categories of unique words,

tð58Þ ¼ 6:83; p , 0:001; information units, tð58Þ ¼ 3:0; p ¼ 0:004; elaborations on topic,

tð58Þ ¼ 13:94; p , 0:001; global coherence, tð58Þ ¼ 3:98; p , 0:001; referential cohe-

sion, tð58Þ ¼ 5:29; p , 0:001; temporal cohesion, tð58Þ ¼ 3:81; p , 0:001; and topic

Table 3

Means and standard deviations of discourse categories for participants (number of occurrences per utterance)

Healthy Impaired

Mean SD Mean SD

Discourse building

Unique words 3.57 1.09 1.98 0.65

Information units 0.88 0.20 0.71 0.23

Conciseness 0.12 0.03 0.13 0.05

Elaborations 0.80 0.23 0.11 0.15

Global coherence 0.25 0.16 0.09 0.15

Local coherence 0.75 0.20 0.67 0.22

CohesionReferential 0.28 0.14 0.25 0.20

Conjunction 0.46 0.19 0.35 0.18

Temporal 0.88 0.27 0.64 0.22

Topic maintenance 0.79 0.23 0.06 0.16

Discourse impairing

Repetitions 0.03 0.02 0.13 0.11

Empty phrases 0.02 0.01 0.08 0.10

Indefinite terms 0.03 0.02 0.08 0.07

Aborted phrases 0.03 0.02 0.07 0.06

Incorrect pronouns 0.02 0.02 0.07 0.05

Disruptive shifts 0.00 0.00 0.04 0.03

K. Dijkstra et al. / Journal of Neurolinguistics 17 (2004) 263–283 273

maintenance, tð58Þ ¼ 14:16; p , 0:001: In all cases, the occurrence of these categories

was higher among healthy adults compared to adults with dementia. No significant

differences were found with regard to conciseness and local coherence. Marginally

significant differences between discourse of older healthy adults and adults with dementia

were found for causal cohesion, tð58Þ ¼ 2:31; p , 0:05:

Conciseness was measured here as the number of information units divided by the

total number of words, an index that is mostly used for picture description tasks

(Tomoeda et al., 1996). In an interview style conversation, it would seem more prudent to

divide the number of information units by the total number of (healthy adult or adult with

dementia) utterances, similar to the procedure used for the other categories. In that case,

differences between healthy older adults and adults with dementia were found, tð58Þ ¼

3:00; p , 0:001; with healthy older adults being more concise than younger adults.

Differences in discourse impairing categories were found for repetitions, tð58Þ ¼ 2:82;

p ¼ 0:007; empty phrases, tð58Þ ¼ 2:92; p ¼ 0:005; indefinite terms, tð58Þ ¼ 3:11; p ¼

0:003; incorrect use of pronouns, tð58Þ ¼ 5:23; p , 0:001; incorrect verb tense, tð58Þ ¼

4:35; p , 0:001; and disruptive topic shifts, tð58Þ ¼ 6:03; p , 0:001: The occurrence of

discourse impairing features was higher in discourse of adults with dementia than that of

healthy adults.

4.2. Conversation partner discourse

The second hypothesis predicted that discourse of conversation partners would be

more facilitative for persons with dementia than for healthy controls. Table 4 shows the

means and standard deviations of conversation partner discourse characteristics.

Conversation partners used more facilitative strategies when talking to a person with

dementia than with a healthy adult. Independent sample t-tests indicated that

conversation partners of persons with dementia used more repetitions, tð58Þ ¼ 4:03;

p , 0:001 and more cues, tð58Þ ¼ 5:12; p , 0:001; than conversation partners of healthy

adults. Conversation partners of adults with dementia used marginally greater

encouragement, tð58Þ ¼ 2:26; p ¼ 0:028 than conversation partners of healthy adults.

There was no difference between conversation partners of the different groups in the use

Table 4

Means and standard deviations for discourse categories of conversation partners (occurrence per utterance)

Healthy Impaired

Mean SD Mean SD

Questions 0.48 0.28 0.39 0.17

Prompts 0.14 0.20 0.14 0.09

Facilitators

Repetitions 0.07 0.09 0.18 0.11

Encouragements 0.13 0.17 0.23 0.19

Cues 0.01 0.02 0.06 0.05

K. Dijkstra et al. / Journal of Neurolinguistics 17 (2004) 263–283274

of prompts as they were instructed to use the same number of prompts, and no difference

in the use of questions.

5. Discussion

The first hypothesis predicted that persons without dementia would display a higher

occurrence of discourse building and lower occurrence of discourse impairing features in

interview style conversations compared to persons with dementia. This hypothesis was

mostly supported by the data. Global coherence, cohesion, information units, topic

maintenance, unique words, and conciseness as an index of utterances instead of words,

but not local coherence, occurred to a greater extent in discourse of healthy adults

compared to persons with dementia. As can be expected, healthy older adults have less

difficulty maintaining conversation than adults with dementia. Apparently, a discourse-

building feature, such as local coherence, is easier to maintain. The lack of differences in

local coherence between the two groups may reflect relatively preserved skills in adults

with dementia until they progress toward more advanced stages of the disease (Dijkstra

et al., 2002). Possibly, cognitive resources are not yet exceeded in the dementia

population when it comes to utterance-to-utterance coherence, which is easier to

maintain than global coherence, as a smaller amount of information needs continued

activation. Since only eight of the 30 adults with dementia would be considered as being

in late or advanced stage based on their MMSE-score, local coherence may not have

declined for the group as a whole.

With regard to discourse impairments, differences were found for all categories,

indicating a profound difference in discourse of healthy older adults and older adults with

dementia. Inevitably, adults with dementia produce language that is more vague,

indefinite, aborted, and repetitive, and has more temporal and referential cohesion errors

and disruptive topic shifts than that of their healthy counterparts.

The results corroborate other studies comparing discourse of healthy and cognitively

impaired adults. The lower occurrence of unique words in discourse of adults with

dementia reflects a more limited vocabulary, a result that was found in a study by

Kempler (1991). Breakdowns in topic maintenance (Bayles, 1985), global coherence and

reduced informativeness (called ‘information units’ in our study) in conversations of

adults with dementia have been demonstrated in other studies as well (Laine et al., 1998).

Similar to our results, Laine and colleagues did not find differences in local coherence in

interviews with AD patients and healthy controls. The higher occurrence of discourse

deficits in discourse of adults with dementia, such as a higher occurrence of empty

phrases, aborted phrases, indefinite terms, repetitions, referential cohesion errors, and

disruptive topic shifts, also corroborates the results of other studies (Almor et al., 1999;

Garcia & Joanette, 1997; Hier et al., 1985; Kempler, 1991; Kempler et al., 1995;

Ulatowska & Chapman, 1991). Our findings indicate that discourse deficits that have

been found in different types of discourse samples of adults with dementia, such as a

picture description tasks (Hier et al., 1985; Tomoeda et al., 1996; Ulatowska &

Chapman, 1991), as well as discourse in more naturalistic settings, such as interviews

(Almor et al., 1999; Laine et al., 2000; Ripich & Terrell, 1988) occur in interview style

K. Dijkstra et al. / Journal of Neurolinguistics 17 (2004) 263–283 275

conversations as well. Whereas most studies focused on a subset of discourse deficits,

our study included a wide range of discourse building and discourse impairing features

of the conversational output.

The second hypothesis predicted a greater use of facilitators in discourse of

conversation partners when talking with persons with dementia, despite having to adhere

to a strict conversation protocol. This hypothesis was supported by the data. Facilitators,

such as repetitions and cues, and to some extent, encouragements, occurred more

frequently in discourse of conversation partners of persons with dementia compared to

discourse of partners of healthy adults.

The results demonstrate clear patterns in the occurrence of discourse building and

discourse impairing features in interview style conversations of persons with and without

dementia, and in the discourse of their conversation partners. First, there is a clear

distinction between discourse of healthy adults and that of persons with dementia. Some

discourse-building features involve higher demands on cognitive resources, such as

continued activation of topic information to establish global coherence, and continued

activation of referential information. Components that require more elaborate cognitive

processing and possibly exceed available capacity are components that cannot be

maintained as easily by persons with dementia and more limited working memory

capacity. This may be a reason why the occurrence of global coherence, topic

maintenance, and causal, referential, and temporal cohesion, was found to be dramatically

lower in conversations of adults with dementia. The relatively higher occurrence of

aborted phrases, repetitions, empty phrases, and disruptive topic shifts in adults with

dementia, may also be indicative of their inability to maintain and process information

under conditions of limited working memory capacity. The higher occurrence of indefinite

words among adults with dementia relative to their healthy counterparts, may reflect

impaired semantic memory function.

Another trend of discourse patterns in conversations between persons with and without

dementia and their conversation partners reflects the recognition by the conversation

partner of the need for repair of communication breakdown when talking with adults with

dementia. Interview protocol violations, such as repetitions and cues occurred more

frequently in conversations between nursing aides and adults with dementia, than in

conversations between healthy older adults and their conversation partner (nursing aide or

experimenter). Apparently, these conversation strategies were considered essential to

enable continuation of the conversation. Otherwise, infringement of protocol procedures

would not seem prudent. Absence of impending communication breakdowns in

conversations with healthy adults enabled those conversation partners to stick closer to

the protocol. The fact that questions occurred in equal numbers in healthy discourse and in

conversations of persons with dementia, suggests that facilitators, such as repetitions and

cues were only added when needed.

The results of this study may be useful in clinical settings where training to improve

conversational skills of persons with dementia could be offered. If conversation partners

are aware of the difficulties persons with dementia have with topic maintenance and

cohesion, they may be able to facilitate the conversation by repeating the topic and

specifying the noun phrase instead of using referents (Almor et al., 1999). When talking

with persons in later stages of dementia, simply repeating information, encouraging

K. Dijkstra et al. / Journal of Neurolinguistics 17 (2004) 263–283276

the person with dementia to keep talking, providing cues, and using external memory aids

(Bourgeois et al., 2001; Dijkstra et al., 2002) may help improve their conversational skills

substantially.

Having a spontaneous conversation is an overlearned and socially supported behavior

that may be a nursing home residents’ only means of contact with fellow residents, staff, or

visitors. Maintaining or improving this skill, especially for residents with dementia may

make a noticeable difference in the quality of life for them. Moreover, if nursing home

staff and family members of residents with dementia can learn relatively easy techniques

to enhance this conversation, the rewards of a communicative interaction without

breakdowns will apply to both parties involved.

Acknowledgements

The authors thank Trish Fain, Rachael Mamalis, Geoffrey Petrie, Martin Schiavenato,

Yasmin Smith, and Tynia Williams for their help in collecting and transcribing the data,

and the staff and residents of the seven participating nursing homes for their support with

the intervention program. The authors thank Barbara Kaup for helpful comments on an

earlier version of this paper.

Appendix A. Guidelines for discourse analysis

T-units (Shadden, 1998a)

Identify as one main (independent) clause plus any subordinate clauses or non-clausal

structures attached to or embedded in the main clause. Number utterances as t-units. Each

t-unit begins on a separate line.

Unique words (Hier et al., 1985)

All words counted that did not occur before. Words, such as ‘do not’ are counted as one

word.

Information units (Tomoeda et al., 1996; Shadden, 1998b)

relevant, truthful, nonredundant facts (Tomoeda et al., 1996)

include content-loaded information units (Shadden, 1998b)

contain relevant, nonredundant, correct information

exclude non-meaningful information units (Shadden, 1998b)

irrelevant, redundant, off-topic, incorrect information

a word that is intelligible in context, accurate in relation to the picture(s) or topic, and

relevant to and informative about the content of the picture(s) or topicother than

references above, it is not an a priori measure in this study coded for every piece of

information in an utterance, but a rating of information unit present or not for each

utterance

informativeness: existence and extent of new information in an utterance, 0 ¼ no new

information, 1 ¼ partially new information, 2 ¼ new information conveyed (Laine et al.,

1998)

K. Dijkstra et al. / Journal of Neurolinguistics 17 (2004) 263–283 277

Conciseness (Hier et al., 1985; Shadden, 1998b; Tomoeda et al., 1996)

A conciseness index was calculated as the ratio of 100 £ (relevant observations/total

words)

Efficiency ratio ¼ number of essential units of information/total words £ 100

Quotient of the number of information units divided by the total number of words,

multiplied by 100

Elaborations on topic (Coelho, 1998)

topic: what are conversations about and how does it change as interaction proceeds

management of topic: how are topics introduced and continued over the course of a

conversation (Mentis, Briggs-Whitaker, & Gramigna, 1995)

subtopic: a sequence in which the focus of discussion is part of and related to the topic

sequence

Coherence (Halliday & Hasan, 1976; Laine et al., 1998)

appropriate maintenance of topic in discourse

Global coherence

the relatedness of an utterance to the general topic of the examiner’s question (Laine

et al., 1998)

Local coherence

an estimate of how closely an utterance is thematically related to the immediately

preceding utterance (or question posed by the examiner; Laine et al., 1998)

Cohesion

Referential includes (Ulatowska & Chapman, 1991; De Santi, Koenig, Obler, &

Goldberger, 1994; Liles & Coelho, 1998; Ripich et al., 2000)

pronominal: all pronouns-I, he, she, her (Ripich et al., 2000)

personal: personal pronouns, possessive determiners and possessive pronouns that

represent a single system of persons, referring to the identity of relevant persons, objects,

and events. Code all personal pronouns (Liles & Coelho, 1998)

demonstrative: verbal pointing, identifying the referent by location in place or time.

Code determiners, such as ‘this’, ‘that’. (Liles & Coelho, 1998)

reference: any use of pronouns or demonstratives (De Santi et al., 1994)

Conjunction (De Santi et al., 1994; Liles & Coelho, 1998)

conjunctions: included adverbial constructions as well as the usual set of coordinating

conjunctions—additive, adversative, causal, temporal, and continuative (De Santi et al.,

1994)conjunctions: identify the systematic relationships between sentences (Ripich et al.,

2000)

causal conjunctions: sentence meanings that cohere through the expression of a

relationship that specifies a result, reason, or purpose, such as ‘so’ (Liles & Coelho,

1998)

adversative conjunctions: sentence meanings that cohere through the expression of

relations that is contrary to the expectation, such as ‘but’ (Liles & Coelho, 1998)

temporal: sentence meanings that cohere via the expression of a relation that specifies

time, such as ‘then’ (Liles & Coelho, 1998)

additive: sentence meanings that cohere simply by denoting added information,

similarity of meaning and alternative meanings. Code markers as additive if they conjoin

K. Dijkstra et al. / Journal of Neurolinguistics 17 (2004) 263–283278

two consecutive sentences that describe events that have occurred simultaneously (Liles &

Coelho, 1998).

conjunction: linking element whose meaning is appropriate to the elements linked

(Ripich & Terrell, 1988)

Topic maintenance (Coelho, 1998)

topics are maintained when they are continued and discontinued in cases of a topic shift

Aborted phrases (Tomoeda et al., 1996)

incomplete phrases that were not revised within two succeeding sentences. Incomplete

phrases lacked a verb, object, or both, and sometimes were a single word

Repetitions (Shadden, 1998a,b)

repetitions of one or more contiguous words or parts of wordsexact repetitions of

syllables, words, or phrases

repeated words or phrases (Nicholas et al., 1985)

Empty phrases (Nicholas et al., 1985)

any utterance that has little or no content

Indefinite terms (Nicholas et al., 1985)

any non specific word, such as ‘thing’, ‘stuff’

Disruptive topic shifts (Garcia & Joanette, 1994; Mentis et al., 1995)

shift of subtopic to other topic or distraction from the environment

Incorrect referent (Ripich and Terrell, 1988;Laine et al., 1998)

No referent: reference to element absent from the text/conversation and not referable

from the context

use of non-referential lexical items: instances where a referring lexical item was used

but its referent was not specified or evident in the immediate context (Laine et al., 1998)

Appendix B

See Tables B1–B3.

Table B1

Excerpts from three transcripts with coding

Resident 1 Codes

A: Yeah, so tell me about your day today. Prompt

How is your day going so far? Facilitator (repetition)

R: Oh. Ok Info unit, local coherence, 1 unique word

A: Umm, so how would you start off this morning? Question

R: Alright. Info unit, local coherence, 1 unique word

I went over and helped Info unit, local coherence, 5 unique words

One of the ladies has a problem trying to get about Info unit, local coherence, 11 unique words

A: Oh, Rose Facilitator (cue)

R: I am trying to think what her name is Info unit, 6 unique words

A: Yeah the lady sitting in the wheel chair that you

just said you’d be back to

Facilitator (cue)

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Katinka Dijkstra Department of Psychology, Florida State University; Michelle Bourgeois, Department of

Communication Disorders, Florida State University; Rebecca Allen and Louis Burgio, Center of Mental

Health, University of Alabama at Tuscaloosa. This paper was supported by grant R01AG13008 from the

National Institute on Aging.

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