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Roles of cognitive status and intelligibility in everyday communication in

people with Parkinson’s disease: A systematic review

Maxwell S Barnish,a,b Daniel Whibley,b Simon MC Horton,a Zoe R Butterfint,a

Katherine HO Deanea

a = School of Health Sciences, University of East Anglia, Norwich, UK

b = Epidemiology Group, Institute of Applied Health Sciences, University of

Aberdeen, Aberdeen, UK

Running title: Everyday communication in PD

Correspondence to: Dr Maxwell S Barnish, Epidemiology Group, Polwarth Building,

Foresterhill Campus, University of Aberdeen, Aberdeen, UK, AB25 2ZD;

[email protected]; (+44) 01224 437217

1

Abstract

Background: Communication is fundamental to human interaction and the

development and maintenance of human relationships and is frequently affected in

Parkinson’s disease (PD). However, research and clinical practice have both tended

to focus on impairment rather than participation aspects of communicative deficit in

PD. In contrast, people with PD have reported that it is these participation aspects of

communication that are of greatest concern to them rather than physical speech

impairment.

Objective: To systematically review the existing body of evidence regarding the

association between cognitive status and/or intelligibility and everyday

communication in PD.

Methods: Five online databases were systematically searched in May 2015 (Medline

Ovid, EMBASE, AMED, PsycINFO and CINAHL) and supplementary searches were

also conducted. Two reviewers independently evaluated retrieved records for

inclusion and then performed data extraction and quality assessment using

standardised forms. Articles were eligible for inclusion if they were English-language

original peer-reviewed research articles, book chapters or doctoral theses

investigating the associations between at least one of cognitive status and level of

intelligibility impairment and an everyday communication outcome in human

participants with PD.

Results: 4816 unique records were identified through database searches with 16

additional records identified through supplementary searches. 41 articles were

suitable for full-text screening and 15 articles (12 studies) met the eligibility criteria.

10 studies assessed the role of cognitive status and 9 found that participants with

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greater cognitive impairment had greater everyday communication difficulties. 4

studies assessed the role of intelligibility and all found that participants with greater

intelligibility impairment had greater everyday communication difficulties, although

effects were often weak and not consistent.

Conclusions: Both cognitive status and intelligibility may be associated with

everyday communicative outcomes in PD. The contribution of intelligibility to

everyday communication appears to be of small magnitude, suggesting that other

factors beyond predominantly motor-driven impairment-level changes in intelligibility

may play an important role in everyday communication difficulties in PD.

Keywords: Parkinson Disease; Cognition Disorders; Speech Disorders;

Communication; Social Participation; International Classification of Functioning,

Disability and Health; Review, Systematic

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Introduction

Parkinson’s disease (PD) is a common neurodegenerative condition that affects

around 1.5% of people over 65 in Europe [1] with considerable worldwide variation in

prevalence [2]. In light of the impact of PD on quality of life [3] and the global ageing

population [4], PD should be considered a major healthcare challenge of the future.

PD was originally characterised largely in terms of its motor features [5], which still

form the basis of recognised diagnostic criteria [6-8]. However, research has

revealed a wide range of non-motor symptoms [9] including cognitive impairment

[10] in over a quarter of patients.

Communication is fundamental to human interaction [11] and the development and

maintenance of human relationships, including those developed in a healthcare

context. Around 70% of people with PD report dissatisfaction with their everyday

communication [12]. The International Classification of Functioning (ICF) [13]

provides a useful framework for conceptualising the distinction between ‘speech’

difficulties at the impairment level and ‘communication’ difficulties at the activity and

especially the participation level. Indeed, the extent of communicative difficulty at the

ICF participation level may not be closely associated with severity of speech

impairment at the ICF impairment level, such as intelligibility [12,14]. Other factors

beyond speech impairment, such as cognitive status [15], may play an important role

in determining participation level outcomes, which we call ‘communicative

participation’ following Eadie et al [16].

In recent years, there has been increased focus on the benefits of service user

involvement in the development and prioritisation of research in order to avoid

mismatch of priorities [17,18]. Miller et al [19] conducted in-depth qualitative

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interviews with people with PD in order to identify the nature of speech and

communication changes, using these terms in the technical senses defined above,

and to assess what impact these changes had on their lives. In this study, “central

concerns were not that voice was monopitch, sound contrasts difficult, or similar…

Rather individuals focused on the impact changes exerted on ability to communicate

[and] their view of themselves”. In contrast, the body of published literature for

impairment-level speech changes in PD is much greater than that about

communication and there is evidence that the ICF participation level does not form a

major focus of many speech and language therapists’ assessment and intervention

practices for PD [20]. Therefore, there appears to be a mismatch between the

priorities of people with PD and those of researchers and clinicians.

In light of this potential mismatch of priorities, it is important to conduct a systematic

and comprehensive appraisal of evidence regarding the associations between i)

speech and communication difficulties in PD and ii) cognitive status and

communication difficulties in PD. This enables evaluation of how closely related the

concepts are that form the respective priorities of people with PD and of researchers

and clinicians. As no summary appraisal of available evidence was identified by a

search of the literature, we decided to conduct a systematic review to address these

research questions and report the findings in this article.

Materials and Methods

We undertook a systematic review of studies investigating the associations between

cognitive status and/or intelligibility and everyday communication in PD. PRISMA

guidelines [21] were followed. Due to the heterogeneity of study designs and

measures, a narrative systematic review rather than a quantitative meta-analysis

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was conducted. This study was a systematic review of existing literature and no

human or animal participants were recruited. Therefore, no ethical approval was

required.

Explicitly stated, our research questions were:

1) To assess associations between cognitive status and communication

outcomes in PD

a) How many studies have assessed the relationship between cognitive

status and communication outcomes in PD, taking the definition of

communication outlined earlier?

b) Of the included studies, what proportion identified a statistically significant

association between at least one measure of cognitive status and a

communication outcome measure in PD?

c) Taking into account all relevant data presented in the included studies, is

the evidence in favour, inconclusive or against with regard to the existence

of an association between cognitive status and communication in PD and

what does it say about the strength of this association?

d) Do the cognitive measures used in the included studies provide insight into

which aspects of cognitive status might be most predictive of degree of

communicative difficulty in PD?

2) To assess associations between intelligibility and communication outcome in

PD:

a) How many studies have assessed the relationship between intelligibility

and communication outcomes in PD, taking the definition of

communication outlined earlier?

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b) Of the included studies, what proportion identified a statistically significant

association between at least one measure of intelligibility and a

communication outcome measure in PD?

c) Taking into account all relevant data presented in the included studies, is

the evidence in favour, inconclusive or against with regard to the existence

of an association between intelligibility and communication in PD and what

does it say about the strength of this association?

Search methods

Five online databases were systematically searched in May 2015: Medline Ovid

(1948), EMBASE (1980), AMED (1985), PsycINFO (1806) and CINAHL (1982). The

search strategy was designed by MSB and KHOD and formed 3 blocks: ‘Parkinson’s

disease’, ‘cognitive status or intelligibility’ and ‘everyday communication’. Key terms

were mapped to database-specific subject headings (MeSH) where available and

exploded to include sub-categories. Items within the blocks were linked with an ‘OR’

Boolean operator and blocks were linked with ‘AND’. The full Medline search

strategy is provided in the supplementary data accompanying this article.

Supplementary searches were conducted by screening bibliographies of extracted

articles and an online search engine (Google Scholar).

Eligibility criteria

For inclusion in the review, articles had to meet the following eligibility criteria:

(1) Full-text original peer-reviewed research article, book chapter or doctoral

thesis

(2) English language publication

(3) Empirical investigation

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(4) Human participants with PD, results being presented separately from other

conditions

(5) Explicit assessment of cognitive status or level of intelligibility impairment

(6) Linkage thereof to oral everyday communication outcomes including

communication-focused pragmatics

(7) Results separable from any investigation of therapy, medicine or surgery

Titles and abstracts were independently assessed for potential inclusion by two

reviewers (MSB and DW) and any disagreements resolved by discussion. Full texts

were obtained where abstracts met eligibility criteria and were independently

assessed by MSB and DW. Those meeting the eligibility criteria were included in the

narrative synthesis.

Data extraction

Data were extracted independently for each included study by MSB and DW. Data

were entered onto standardised forms capturing study characteristics and study

measures and results respectively (see supplementary data accompanying this

article), subsequently synthesised into a summary of findings table (Table 1). Where

appropriate, articles were grouped into studies.

Quality assessment

Quality assessment was conducted using the Threats to Validity tool [22], which

KHOD previously helped to develop. It was configured for the purposes of our review

by MSB and KHOD. Quality was assessed independently by MSB and DW for each

included study, enabling generation of a ‘Threats to Validity Table’ (Table 2) profiling

the methodological performance of each study. Following Daley et al [22], studies

were assessed as at overall low risk of bias (High quality) if ≥70% of applicable

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quality items were assessed as at low risk of bias, overall moderate risk of bias

(Moderate quality) for 40-69% and overall high risk of bias (Low quality) for ≤39%.

Results

Database searches yielded 4816 unique records. Sixteen additional records were

identified through supplementary searches. Figure 1 shows the PRISMA flow chart

depicting each stage of study identification. After reviewing abstracts, 41 were

suitable for full text retrieval. Following thorough evaluation, 15 articles [12,14-15,23-

34] (12 studies) met the eligibility criteria.

Summary of studies

Eight studies assessed only cognitive status as a predictor of communicative

difficulties, two studies only assessed intelligibility as a predictor and two studies

assessed both cognitive status and intelligibility as predictors. Ten studies used a

cross-sectional design, one used a cohort study design and one used a mixed

methods design. Five studies were conducted in the USA, four in the UK, two in

Canada and one in New Zealand. Two studies were assessed at low risk of bias, five

at moderate risk of bias and five at high risk of bias (Table 2). The three most

common threats to validity were a lack of participant representativeness (11 studies,

92%), concerns over task or stimulus order effects (11 studies, 92%) and a lack of

sample size rationale (10 studies, 84%). The approach to intelligibility assessment

undertaken by each study is profiled in Table 3. The findings of included studies are

summarised below and provided in full in the Appendix.

Cognitive status

Ten studies assessed the role of cognitive status and 9 found a positive result,

defined as a significant association between at least one measure of cognitive status

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and one measure of everyday communication. Of these nine studies, one [25] was

assessed at low risk of bias, four [15,24,29,33-34] at moderate risk of bias and four

[23,28,31,32] at high risk of bias. Five [28,30,31,33,34] of these studies provided

evidence that greater impairment of cognitive status is associated with greater

impairment of conversational pragmatics. Hall et al [28] found that Mini Mental State

Examination (MMSE) [35] score was strongly associated with score on the Rating

Scale of Pragmatic Communication Skills [36]. McKinlay et al [30] found that

measures of working memory and processing speed, but not attentional set-shifting,

predicted pragmatic communication on the Test of Linguistic Competence-Extended

[37]. McNamara et al [31] found that Stroop [38] and Tower of London [39] test

parameters were associated with score on the Pragmatic Protocol [40]. Monetta et al

[33] found that verbal working memory and verbal fluency predicted aspects of the

Discourse Comprehension Test [41]. Pell et al [34] found that the ability to make

enriched social inferences on The Awareness of Social Interference Test [42] was

associated with working memory capacity and frontal lobe functioning.

Three studies [15,23,24,29] found an association between cognitive status and

narrative organisation and/or turn taking. Alpert et al [23] found that a composite

dementia score was negatively associated with frequency of internal pauses and

frequency of simultaneous speech and positively associated with mean length of

internal pauses. Ash et al [24] found that reverse digit span, letter-guided fluency,

category fluency and Stroop time were associated with communicative parameters

from the analysis of story narration. Lesser et al [15,29] found that while PD

subcortical dementia and PD with Lewy body dementia groups did not differ overall

with regard to conversation analysis parameters, people with PD and Lewy body

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dementia had more difficulty orienting the conversation partner to a new topic and

retained fewer pre-morbid communicative situations.

One study [25] found that worse Montreal Cognitive Assessment (MoCA) [43] score

was associated with greater impairment of everyday communication as measured

the Communicative Participation Item Bank (CPIB) [44] but not the Communicative

Effectiveness Survey (CES) [14]. Sub-domain analysis was reported. MoCA

‘Naming’ sub-scale was identified as a predictor of CES score, while MoCA

‘Executive and Visuospatial’ and ‘Attention’ subscales were marginal predictors of

CPIB.

One study [12,32] had a negative result. It was assessed as high quality and

investigated the association between cognitive status and communicative

effectiveness as measured through a semantic differential questionnaire.

Intelligibility

Four studies assessed the role of intelligibility and all found a statistically significant

association between at least one measure of intelligibility and one communicative

outcome, representing a positive result by our definition. Two [12,25,32] were

assessed at low risk of bias, one [14,27] at moderate risk of bias and one [26] at high

risk of bias. Barnish [25] found that conversational sentence intelligibility was a

significant predictor of both CPIB and CES, accounting for 43% and 19% of the

variance respectively, while read sentence intelligibility did not significantly predict

these communication outcomes. Coates and Bakheit [26] found that there was a

significant difference in intelligibility scores between those who complained of

everyday communication difficulties and those who did not. Donovan et al [14,27]

found a significant association between intelligibility and CES, although it accounted

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for only 15% of variance. Miller et al [12, 32] found that intelligibility was a weak

(r = - 0.23) but statistically significant predictor of communicative change according

to a semantic differential questionnaire at baseline but not at follow-up.

Discussion

The systematic review reported in this article is the first to address the contribution of

either cognitive status or intelligibility to everyday communication difficulties in PD.

Of the ten studies that assessed the role of cognitive status, nine found evidence of

this association and the other study [12,32] relied on MMSE, which has been

demonstrated to be insensitive to milder cognitive impairment in PD [45-46]. The

balance of evidence is in favour of an association between cognitive status and

everyday communication in PD including communicative participation,

conversational pragmatics and narrative organisation/turn-taking. With regard to the

implication of specific cognitive functions, there is preliminary evidence that

executive function might be implicated, although before any conclusions can be

drawn this requires further exploration in future studies, which may also seek to

assess neural correlates using imaging techniques. Of the four studies that assessed

the role of intelligibility, all found evidence of a significant association. However, the

strength of association differed regarding on the nature of the intelligibility

assessment and the communicative outcome measure. Overall, the contribution of

intelligibility deficits to everyday communication difficulties appeared of modest

magnitude.

The first key conclusion of this systematic review is that we found evidence to

suggest that both cognitive status and intelligibility may be associated with everyday

communicative outcomes in PD. The second key conclusion is that the contribution

12

of intelligibility to everyday communication, while statistically significant, appears to

explain a relatively small proportion of the variance in everyday communication

outcomes. This, in turn, suggests that other factors beyond predominantly motor-

driven impairment-level changes in intelligibility may play an important role in

everyday communication difficulties in PD.

These conclusions must, however, be viewed as preliminary since there are several

key limitations in the identified body of literature. Firstly, most included studies were

cross-sectional, which preclude definitive inference of causality [47] since they

provide no information on the time sequence of the hypothesised exposure and

outcome. Secondly, only two of the 12 studies (17%) were assessed at low risk of

bias and five (42%) were assessed at high risk of bias, suggesting that study quality

in this field of inquiry may be problematic. Thirdly, only 2 studies (17%) reported a

sample size rationale and the median number of people with PD included per study

was only 18.5, showing that most studies used small samples. Therefore, many

included studies may have limited statistical power and be limited in their

generalisability beyond the sample.

Everyday communication is fundamental to successful functioning [11], and

difficulties in this area are both common [12] and seen as a priority by people with

PD [19]. However, established paradigms in the conceptualisation and treatment of

communicative difficulties in PD have focused predominantly on impairment-level

motoric alterations in speech. For example, evidence from surveys of UK speech

and language therapists has shown that everyday communication, especially at the

participation level, does not form a major focus of many therapists’ assessment and

intervention practices for PD [20] and progressive dysarthria more generally [48].

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This is despite clinical guidelines [49] and a belief by both clinicians [48] and people

with PD [19] that communicative participation is important.

Indeed, the number of studies eligible for inclusion in our systematic review is

relatively small. The vast majority of studies assessing speech in PD have not looked

at changes beyond the ICF impairment level. The reasons for this focus are

unknown, although they may parallel a similar situation in clinical practice [20,48].

One possible explanation is the lack until relatively recently of any self-report

measure that solely measured communicative participation [16]. CPIB offers the

prospect of addressing this shortage. CPIB was developed using item-response

theory [50] and subsequently validated in PD in the USA and New Zealand [51] as

well as the UK [25]. In light of its relatively recent development, CPIB was only used

in one study [25] included in this review. Studies varied considerably in terms of the

outcome measures used and many measures did not adequately distinguish ICF

Activity and Participation level effects. Moreover, the studies by Hall et al [28],

McKinlay et al [30], McNamara et al [31], Monetta et al [33] and Pell et al [34] used

outcome measures that focused on specific aspects of pragmatic communicative

functioning, which may not be generalizable to other aspects of everyday

communication. Issues of measurement need to be addressed in future studies.

Issues regarding how intelligibility was assessed in included studies also need to be

considered. As profiled in Table 3, the four studies that assessed intelligibility shared

some commonalities but also had some considerable differences with regard to

intelligibility assessment. All four studies conducted all or most of the recordings in

participants’ own homes. This is likely to offer a more realistic real-world recording

environment than a studio recording, but would lack the extent of background noise

encountered in certain common everyday communicative situations such as cafes

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and community centres. Two studies [14, 26,27] did not address stimulus

organisation, while Barnish [25] used a blended presentation approach using Latin

Square [52] allocation of stimuli to assessors and a randomised presentation order to

minimise stimulus exposure effects and learning biases [53,54] and Miller et al

[12,32] randomly assigned whole recordings of speakers to assessors. Two studies

[14, 25, 27] presented stimuli in context, one study without context [12,32] and one

study [26] did both. One study [25] used a large pool of assessors without expertise

in speech disorders, one study [12,32] used a small number of assessors without

expertise in speech disorders and two studies [14, 26, 27] used a small number of

expert listeners. All four studies used transcription tasks. Intelligibility assessments

may lack comparability across studies and task-specific effects may limit

generalisability. It is possible to suggest that intelligibility assessment tasks may

overestimate the deficit when transferred to everyday communicative situations,

which in turn could in part explain the weak association between intelligibility and

everyday communication outcomes. However, this is not supported by the finding of

Barnish [25] that conversational speech intelligibility predicted communicative

outcomes, while read speech intelligibility did not.

If confirmed in further, more rigorous studies, the findings presented in our

systematic review that intelligibility does not appear particularly strongly associated

with the degree of everyday communication difficulties in PD, and that other factors

such as cognitive status may play an important role, would present a challenge to

prevailing assessment and treatment practices. Further research is required to

confirm these findings. It is recommended that future studies i) are designed in

accordance with rigorous quality assessment tools, ii) have sufficient sample size to

address issues of statistical power and generalisability and iii) use prospective cohort

15

designs to offer greater insight into temporal relations. Moreover, the investigation of

communicative outcomes could be embedded into large cohort studies of the

general natural history of PD to provide access to larger, more representative

samples. In addition, if research in this field could agree upon a standard set of

cognitive, intelligibility and communicative measures, this could facilitate meta-

analysis.

This systematic review has a number of key strengths. Firstly, it is the first

systematic evaluation of the extant body of evidence relating intelligibility and

cognitive status to everyday communication in PD. Secondly, searches covered five

key bibliographic databases with supplementary searches to minimise risk of

selection bias. Thirdly, rigorous standardised screening and data extraction

techniques were used. Fourthly, quality assessment was conducted with a tool that

was specifically designed for use in assessing observational studies. Fifthly, review

procedures were conducted independently by two reviewers as a quality assurance

measure. There are, however, a couple of limitations that should be considered.

Firstly, only articles published in English were considered. However, English is the

primary international language of scientific communication and there is evidence that

potential language bias does not significantly affect the result of systematic reviews

[55]. Secondly, the heterogeneity of study methods, including both exposure and

outcome measurement, precluded the use of meta-analysis, which could have

provided a pooled estimate of effect size.

Acknowledgements including sources of support

We acknowledge funding from a University of East Anglia (UEA) PhD studentship to

MSB, during whose PhD at UEA the idea for this systematic review was conceived

16

and an early version conducted. The idea for this systematic review was conceived

by MSB (Chief Investigator), KHOD, SMCH and ZRB. Project management was

conducted by MSB. Searches were designed by MSB and KHOD and then executed

by MSB. Screening, data extraction and quality assessment were conducted by MSB

and DW with advice from KHOD. All authors contributed to the interpretation of the

findings. MSB wrote the first draft of the manuscript and all authors contributed to

revisions and approved the submission.

Conflicts of Interest

The authors have no conflict of interest to report.

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Tables

Table 1. Summary of systematic review findings

Factor N studies Total sample size

Results summary

Quality summary

Cognitive status

10 291P = 9

H = 1M = 4L = 4

N = 1H = 1M = 0L = 0

Intelligibility

4 222P = 4

H = 2M = 1L = 1

N = 0H = 0M = 0L = 0

P = positive study – defined as providing evidence of at least one significant association between the relevant predictors and outcomes, N = negative study, H = high quality, M = moderate quality, L = low quality – calculation details given in methods section

24

Table 2. Threats to Validity table profiling risk of bias in included studies

Threats to validity Alpert Ash Barnish Coates

Donovan Hall

Lesser McKinlay

McNamara Miller Monetta Pell

Selection bias (Diagnostic accuracy)

? ? ? ? ? ?

Selection bias (Participant representativeness)

? ? ? ? ? ? ? ?

Selection bias (Group equivalence)

NA NA NA ? NA

Chance (Sample size rationale)

? ? ? ? ? ? ? ? ? ?

Detection bias (Task validity)

Detection bias (Order effects)

? ? ? ? ? ? ? ? ? ? ?

Detection/Reporting bias (Appropriate analysis)

? ? ? ?

Reporting bias (Conflict of interest)

?

Quality summary

% ✓ 29 50 71 14 63 38 50 38 38 86 63 50Classification L M H L M L M L L H M M

✓ = high quality (low risk of bias), = low quality (high risk of bias), ? = unclear, NA = not applicable to study design. H = overall high quality, M = overall moderate quality, L = overall low quality – calculation details given in methods

25

Table 3. Profiling of intelligibility assessment

First author Recording environment

Stimulus organisation

Intelligibility in context or without context?

Number of assessors

Assessor expertise

Assessment task

Barnish Recorded in participants’ homes

A blended presentation approach was used. The allocation of stimuli to assessors followed Latin Square and presentation order was randomised

In context 64 Staff or students of the University of East Anglia without expertise in speech disorders

Transcription

Coates Recorded in participants’ homes

Not stated In context and without context

8 Speech and language therapists

Transcription

Donovan Recorded in participants’ homes (71/75) or in clinic (4/75)

Not stated In context 3 Speech and language therapists

Transcription

Miller Recorded in participants’ homes

Each assessor was randomly assigned the recordings of 5 different speakers

Without context

3 Assessors were unfamiliar with Parkinson’s disease

Transcription

26

Figure legends

Figure 1. PRISMA flow chart

27

Figures (600 dpi TIFF)

28

Supplementary data

Table of studies excluded at full-text screening with reasons

First author Year Title Publication details

Reason for exclusiona

Anderson 2013 Social problem solving, social cognition, and mild cognitive impairment in Parkinson’s disease

Behav Neurosci 127(2): 184-92

Not focused on everyday communication

Ash 2012 The organization and anatomy of narrative comprehension and expression in Lewy body spectrum disorders

Neuropsychology 26(3): 368-384

Not focused on oral medium

Baylor 2011 A qualitative study of interference with communicative participation across communication disorders in adults

Am J Speech Lang Pathol 20(4): 269-87

No explicit linkage of either cognitive status or intelligibility to communicative outcomes

Berg 2003 High-level language difficulties in

Clin Linguist Phon 17(1): 63-80


Brown 2013 Social participation and speech impairment in Parkinson’s disease

J Med Speech Lang Pathol 20(4): 30-35


Calne 2003 The psychosocial impact of late-stage Parkinson’s disease

J Neurosci Nurs 35(6): 306-13

Article type

Donovan 2007 The communicative effectiveness survey: Investigating its item-level psychometric properties

J Med Speech Lang Pathol 15(4): 433-47


Fusegi 2012 The Unrelated Communication Interlude (UCI) – An automatic behavior phenomenon in Parkinson’s disease

Parkinsonism Relat Disord 18(8): 986-9


Griffiths 2013 Potential causes and consequences of overlap in talk

Semin Speech Lang 33(1): 27-43

No explicit linkage of either cognitive status or intelligibility

29

between speakers with Parkinson’s disease and their familiar conversation partners

to communicative outcomes

Holtgraves 2010a Pragmatic comprehension deficit in Parkinson’s disease

J Clin Exp Neuropsychol 32(4): 388-97


Holtgraves 2010b Parkinson’s disease and politeness

J Lang Soc Psychol 29: 178-93


Jaywant 2010 Listener impressions of speakers with Parkinson’s disease

J Int Neuropsychol Soc 16(1): 49-57


McNamara 2010 Social cognition of indirect speech: Evidence from Parkinson’s disease

J Neurolinguistics 23(2): 162-71


McNamara 2006 Life goals of patients with Parkinson’s disease: A pilot study on correlations with mood and cognitive functions

Clin Rehabil 20: 818-826


Martens 2011 Assessment of prosodic communicative efficiency in Parkinson’s disease as judged by professional listeners

Parkinsons Dis 2011: Article ID 129310

Not focused on everyday communication (impairment level only)

Miller 2006 Life with communication changes in Parkinson’s disease

Age Ageing 35(3): 235-9


Monetta 2009 Irony comprehension and theory of mind deficits in patients with Parkinson’s disease

Cortex 45(8): 972-81


30

Monetta 2007 Effects of verbal working memory deficits on metaphor comprehension in patients with Parkinson’s disease

Brain Lang 101(1): 80-9


Mott 2004 Only misunderstood? The effects of Parkinson’s disease on interactions with health professionals

Aust J Prim Health 10(2): 82-9


Pell 2006 The impact of Parkinson’s disease on vocal-prosodic communication from the perspective of listeners

Brain Lang 97(2): 123-34

Not focused on everyday communication (impairment level only)

Pitcairn 1990 Impressions of parkinsonian patients from their recorded voices

Br J Disord Commun 25(1): 85-92


Saldert 2014 Semantic trouble sources and their repair in conversations affected by Parkinson’s disease

Int J Lang Commun Disord 49(6): 710-21


Tremblay 2015 The effects of subthalamic deep brain stimulation on metaphor comprehension and language abilities in Parkinson’s disease

Brain Lang 141: 103-9

Not separable from surgical intervention

Tremblay 2014 The role of polysemy on metaphor comprehension processing: The example of Parkinson’s disease

J Neurolinguistics 30(1): 1-13


Walshe 2009 Dysarthria Impact Profile: Development of a scale to measure psychosocial effects

Int J Lang Commun Dis 44(5): 693-715

Results from people with PD not presented separately

31

Walshe 2008 Intelligibility of dysarthric speech: Perceptions of speakers and listeners

Int J Lang Commun Disord 43(6): 633-48

Results from people with PD not presented separately

a = primary reason for exclusion listed for each excluded article - some articles could have been justifiably excluded for more than one reason

32

Full Medline search strategy(exp parkinson disease/)

AND

(exp cognition/ OR exp cognition disorders/ OR exp dementia/ OR exp memory/ OR exp memory disorders/ OR exp neuropsychology/ OR planning.mp OR exp problem solving/ OR exp executive function OR exp learning/OR exp social perception/ OR social cognition.mp OR visuospatial function.mp OR exp speech disorders/ OR exp dysarthria/ OR speech characteristics.mp OR exp speech acoustics/ OR exp speech intelligibility)

AND

(exp communication/ OR exp communication disorders/ OR pragmatics.mp OR communicative effectiveness.mp or communicative participation.mp OR everyday communication.mp OR social communication.mp OR conversation.mp)

This was translated for searches conducted on other databases

33

Detailed study characteristics

First author

Year Country Design Sizeb Commercially funded

Diagnostic criteria for PD

Other inclusion criteria

Participant characteristics

Alpert 1990 USA Cross-sectional

10 No IPD (H&Y 3-4) Mild-to-moderate dementia. No psychiatric conditions or substance abuse

N = 10; male = 80%; Mean age = 77 years; mean disease duration (DUR) = 6 years

Ash 2011 USA Cross-sectional

14a No PD (Hughes criteria)

No other causes of dementia

N = 14; male = 71%; Mean age = 73; DUR = 7

Barnish 2013 UK Cross-sectional

45 No IPD (PDBB criteria)

No clinical evidence of dementia or previous serious medical conditions that could affect cognition or speech. Judged by clinics to be suitable for the study

N = 45; male = 62%; age = 71, DUR = 7 (median)

Coates 1997 UK Cross-sectional

48 Unknown

Clinically diagnosed IPD

No severe intercurrent illness or clinical evidence of dementia

N = 48; male = 42%; age = 70; DUR = 7

Donovan

2008, 2005

USA Cross-sectional

25 No PD (H&Y1-4) Aged between 18 and 90. No history of neurologic, psychiatric or language deficit. MMSE ≥23. Not

N = 25; male = 56%; age =70

34

H&Y stage 5. Dysarthric but not anarthric. Native English speaker who could read and has sufficient hearing to follow instructions. Living in the community.

Hall 2011 USA Cross-sectional

17 No IPD (Gelb criteria) Had to be able to provide a control participant

N = 17; male = 71%; age = 61, DUR = 8

Lesser 1999, 1999

UK Mixed methods

12 No PD and subcortical dementia (Cummings criteria) or PD with Lewy body dementia (McKeith criteria)

None N = 12; PD subcortical dementia male = 100%; age = 72; PD with Lewy body dementia male = 50%; age = 68

McKinlay

2009 NZ Cross-sectional

40 No Clinically diagnosed IPD (specialist neurologist)

MMSE ≥ 25 and premorbid IQ≥ 85. No current involvement in a therapeutic trial, history of moderate-to-severe head injury, stroke or other neurological impairment or significant psychiatric illness requiring

N = 40, age = 66

35

hospitalisation. No major depression in last 6 months (Beck score >16). Not currently taking medication known to affect CNS

McNamara

2003 USA Cross-sectional

20 No Clinically diagnosed PD

No clinical dementia (DSM-III) or history of substance abuse or head injury. Male and right-handed

N = 20; male = 100%; age = 72; DUR = 9

Miller 2011, 2008

UK Cohort 104 No IPD (PDBB criteria)

H&Y ≤ 3 at assessment. No comorbid conditions likely to affect communication. No DBS or SLT treatment. Native English speaking.

N = 104; age = 72; DUR = 7

Monetta 2008 Canada Cross-sectional

14 No IPD (Calne criteria) No dementia (Mattis scale), other serious medical conditions or history of substance or alcohol abuse

N = 14; age = 66

Pell 2014 Canada Cross-sectional

15 No Clinically diagnosed PD

No dementia (Mattis scale), other neurological conditions, major psychiatric conditions or history

N = 15; male = 53%, age = 71; DUR = 11

36

of alcohol abusea = outcome of interest was only studied in the PD dementia group (n = 14), b = sample size of all patients fulfilling inclusion criteria for this review. CNS = central nervous system, DBS = deep brain stimulation, DSM = Diagnostic and Statistical Manual of Mental Disorders, DUR = disease duration, H&Y = Hoehn and Yahr scale, IPD = idiopathic Parkinson’s disease, MMSE = Mini Mental State Examination, NZ = New Zealand, PD = Parkinson’s disease, PDBB = UK Parkinson’s Disease Society Brain Bank, SLT = speech and language therapy;, UK = United Kingdom, USA = United States of America.

37

Detailed study results

First author Year Intelligibility measuresa Cognitive measuresa Communicative measures

Results

Alpert 1990 None Composite dementia scale

WELMAR Dementia was negatively associated with frequency of internal pauses (r = -0.53) and frequency of simultaneous speech (r = -0.53) and positively associated with mean length of internal pauses (r = 0.58)

Ash 2011 None Comprehensive neuropsychological assessment

Analysis of narration of story

Reverse digit span was associated with local connectedness (r = 0.61, p<0.05). Letter-guided fluency was associated with local connectedness (r = 0.70, p<0.05) and search theme maintenance (r = 0.60, p<0.05). Category fluency was associated with local connectedness (r = 0.62, p<0.05) and search theme maintenance (r = 0.64, p<0.05). Stroop time was associated with search theme maintenance (r = -0.70, p<0.05). No other associations were significant including all associations with global connectedness.

Barnish 2013 AssIDS, conversational sentence intelligibility

MoCA CES, CPIB Read sentence intelligibility (AssIDS) did not predict CES or CPIB. Conversational sentence intelligibility predicted CES (F = 13.65, p = 0.002, η2 = 0.43) and CPIB (F = 4.96, p =0.04, η2 = 0.19). MoCA predicted CPIB (F = 8.99, p = 0.005, η2 = 0.15) but not CES. With regard to MoCA sub-domains, MoCA Naming predicted CES (F = 4.07, p<0.05, η2 = 0.07) and

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MoCA Executive and Visuospatial (F = 3.22, p = 0.08, η2 = 0.05) and Attention (F = 3.05, p = 0.09, η2 = 0.05) were marginal predictors of CPIB

Coates 1997 Modified Y&B Assessment Scale

None Self-report There was a significant difference in intelligibility between those who complained of difficulties communicating with either strangers or family and friends and those who did not (p<0.01)

Donovan 2008, 2005

SIT, SSI None CES There was a significant zero order correlation between SIT and CES (r = 0.82, p<0.001) but not between CES and SSI. SIT and SSI accounted for only 15% of variance in CES.

Hall 2011 None MMSE RSPCS MMSE was associated with RSPCS (r = 0.81, p = 0.002)

Lesser 1999, 1999

None Patients subdivided into PD with subcortical dementia and PD with Lewy body dementia

CAPPCI Overall, PD subcortical dementia and PD with Lewy body dementia groups did not differ with regard to CAPPCI parameters. However, PD with Lewy body dementia group had more difficulty orienting the conversation partner to a new topic and retained fewer pre-morbid communicative situations

McKinlay 2009 None ID/ED from CANTAB, Daneman and Carpenter Reading Span test, colour naming, D-KEFS

TLC-E Working memory (Sobel’s z – 2.90, p<0.01) and processing speed (Sobel’s z = 3.40, p<0.001), but not attentional set-shifting, explained deficits in pragmatic functioning as indexed by TLC-E according to path analyses

McNamara 2003 None FAS verbal fluency, MMSE, Stroop,

Prutting and Kirchner

Stroop test (r = 0.63, p = 0.01) as well as Tower of London time to first move (r = -

39

Tower of London, design fluency

Pragmatic Protocol

0.46, p = 0.05) and time per move (r = -0.50, p = 0.05) were associated with the pragmatic protocol. No other significant associations were found

Miller 2011, 2008

Speech intelligibility test MMSE Semantic differential questionnaire

Cognitive status was not associated with greater perceived communicative change at baseline or follow-up. There was a weak but significant association between communicative change and intelligibility at baseline (r = -0.23, p = 0.03) but not follow-up

Monetta 2008 None Comprehensive neuropsychological assessment

Discourse comprehension test

Verbal working memory was associated with the ability to draw inferences (r = 0.66, p<0.05) and answer questions about stated details (r = 0.57, p<0.05). Verbal fluency was associated with ability to answer questions about implied main ideas (r = 0.61, p<0.05) and stated details (r = 0.56, p<0.05). No other significant associations were found

Pell 2014 None Comprehensive neuropsychological assessment

TASIT The ability to make enriched social inferences was associated with working memory capacity (r = 0.74) and frontal lobe functioning (r = 0.72)

a = only when used to assess relationships to outcome measures. AssIDS = Assessment of Intelligibility of Dysarthric Speech, CANTAB = CAmbridge Neuropsychological Test Automated Battery, CAPPCI = Conversation Analysis Profile for People with Cognitive Impairment, CES = Communicative Effectiveness Survey, CPIB = Communicative Participation Item Bank, D-KEFS = Delis Kaplan Executive Function System, FAS = Frontal Assessment Scale, ID/ED = Intradimensional/Extradimensional, MMSE = Mini Mental State Examination, MoCA = Montreal Cognitive Assessment, PD = Parkinson’s disease, RCPCS = Rating Scale of Pragmatic Communication Skills, SIT = Sentence Intelligibility Test, SSI = Spontaneous Speech Intelligibility, TASIT = The Awareness of Social Interference Test, TLC-E = Test of Language Competence – Extended, Y&B = Yorkston and Beutelman.

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