The Assessment and Management of Cognitive-Communication Disorder in Parkinson’s Disease: Is Telepractice a Viable Alternative?

Cognitive-communication disorders are a common sequela in people with Parkinson’s disease (PwPD). Deficits are shown in the expression and comprehension of language as well as pragmatic communication behaviours. This impairment can have a detrimental impact on social participation, which can lead to withdrawal and feelings of frustration and isolation. Speech-language pathologists (SLP) are trained to assess and manage communication disorders. However, there is currently a lack of evidence on the clinical assessment and management of cognitive-communication disorders in PD. Despite this, SLPs are qualified to manage language and cognitive-communication in other clinical populations, and therefore, can provide PwPD with support. While speech-language pathology services are crucial in maintaining communicative function and quality of life (QoL), access to such services is limited on an international scale. There are several common barriers that prevent access to services, including the geographical spread of the population with the majority of health services based in metropolitan cities. One potential solution to overcome service barriers is telepractice. Telepractice is a service delivery model that harnesses technology and the internet to provide services from a distance. There is the potential for telepractice to increase access to services while also improving the quality and continuity of care. There is currently a lack of evidence for the use of telepractice to assess and manage cognitive-communication disorders in PD. Similarly, the perceptions of SLPs and PwPD in the use of telepractice as a mode of service delivery have not been explored.Overall the aims of this thesis were to 1) To investigate the current clinical practices of SLPs in Australia for managing cognitive-communication changes in PD and their views on telepractice, 2) To investigate the cognitive-communication difficulties of PwPD in Australia, access to speech language pathology services, and views on telepractice, 3) Determine the feasibility, validity, and reliability of an evidence-based assessment protocol for cognitive-communication function in PD via telepractice, and 4) Develop a potential evidence-based protocol for the management of cognitive-communication deficits in PD via telepractice. In order to address the thesis aims, a series of six studies were conducted from which five manuscripts were produced.Chapter 2 includes two studies which report on the development of two national surveys, one for SLPs (reported in Chapters 3 and 4) and one for PwPD (reported in Chapter 5 and 6). As a part of the survey development process, two qualitative semi-structured interview studies were conducted with PwPD (n=10) and SLPs (n=8) on the main topics of the proposed surveys. The remainder of this chapter reports on the development and testing process used to produce the final versions of the surveys.Chapter 3 (study three-part A) reports on the outcomes of the first part of the clinicians' national survey (n=99). This study investigated the types of assessment and management methods used for cognitive-communication in PD, as well as current issues on service delivery and accessing services. Chapter 4 (study three-part B) reports on the second part of the national survey regarding telepractice (n=63). This study found that SLPs view telepractice as a viable service delivery option for PwPD, but there are barriers that prevent uptake and implementation in current practices.Chapter 5 (study four-part A) investigated the communication changes experienced by PwPD (n=78) as well as their access to speech-language pathology services. Cognitive-communication impairments were frequently reported, but access to speech-language pathology services was low. Barriers that prevented access to services included lack of knowledge about speech-language pathology and the timeliness of referrals by primary care providers. Chapter 6 (study four-part B) reported on the telepractice section of the national survey. Overall, PwPD (n=70) had positive perceptions of telepractice for speech language pathology services. Several factors, such as ease of use of technology and financial reimbursement, were identified as important when considering telepractice.Chapter 7 (study five) reports on the feasibility, validity, and reliability of an evidence-based practice assessment protocol for cognitive-communication disorders in PD via telepractice. The protocol was selected based on the convergence of evidence from the current literature and SLPs assessment practices. The assessments chosen were the Montreal Cognitive Assessment (MoCA), Subtests of the Boston Diagnostic Aphasia Examination (BDAE-3), and the Mt Wilga High-Level Language Test (MWHHLT). This study found the assessments to be feasible to deliver online, with the majority of subtests attaining high validity, and inter-rater and intra-rater reliability.Chapter 8 (study six) outlines the development of a potential intervention protocol for cognitive-communication disorders in PD through triangulation of survey data from chapters 3 and 5 and group performance data from the assessments conducted in chapter 7. A task analysis was also conducted on this protocol to guide the selection of appropriate technology for delivery via telepractice in future research trials.The final chapter of the thesis (Chapter 9) provides an overview of the project findings, limitations, clinical implications, and areas for future research. In summary, this thesis provides evidence that: PwPD experience cognitive-communication disorders but currently have poor access to speech-language pathology services; many SLPs recognise the need to target cognitive-communication disorders in PD and the need for increased research evidence to support the management of this impairment; SLPs and PwPD perceive telepractice as a viable service delivery model; an assessment protocol for cognitive-communication disorder in PD via telepractice is feasible with most subtests achieving high validity and reliability, and finally an evidence-based practice intervention protocol for cognitive-communication disorders in PD delivered via telepractice has been developed for Phase I trials.

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