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Multilingual Interaction and Dementia
By Charlotta Plejert, Camilla Lindholm, Robert W. Schrauf Multilingual Matters
Copyright © 2017 Charlotta Plejert, Camilla Lindholm, Robert W. Schrauf
All rights reserved.
ISBN: 978-1-78309-768-5
CHAPTER 1
Multilingual Interaction and Dementia
Charlotta Plejert, Camilla Lindholm and Robert W. Schrauf
Introduction
The purpose of this book is to shed light on multilingual, everyday conversational and clinical interactions among multilingual persons with dementia, their caregivers and families. If Grosjean (1994) was correct in estimating that half of the world's population uses more than one language or dialect in everyday life, then clearly there are many older adults with dementia who both speak more than one language and whose daily interactions are likely to be multilingual. Nevertheless, as we discuss below, there is little literature on the specific issue of multilingualism and actual talk-in-interaction among persons with dementia, their caregivers and family members. The various contributors conduct detailed description and careful analysis of such interactions for the purpose of enriching our understanding of multilingualism and dementia and developing a solid empirical foundation for improving communication and quality of life of multilingual persons with dementia, their relatives, staff in residential care and clinical practitioners. Each chapter highlights practices and actions employed by interlocutors to facilitate mutual understanding, enhance high-quality social relations and assure optimal care and treatment, in spite of language and cognitive challenges. The term multilingual is used in a broad sense here, in order to capture the large range of settings and circumstances in which persons with dementia find themselves, illustrated in the various chapters. Most participants in the studies presented in this volume speak or have actively acquired and used two or more languages over their lifespan, but some of the chapters also highlight social encounters of persons with dementia who have less balanced competence in their various languages. An example of this complex language landscape could be a Kurdish woman from Iraq, with Kurdish as her mother tongue, also speaking some Arabic and Turkish, who has migrated to Sweden in old age to live with her daughter. Her knowledge of the language of the host country might therefore be quite limited. Living with her family is possible until her condition makes medical attention and professional care necessary, so she moves into residential care. In the residential care unit, caregiving staff might either be monolingual speakers of Swedish, or speaking Swedish as a second language, not necessarily being competent in any of the woman's languages. Thus, the different chapters of this book do not only deal with persons with dementia who are multilingual, but with settings permeated by the different languages and cultures of all participants involved. By means of detailed scrutiny of interaction, it is demonstrated how these participants, together, navigate through the maze of mundane as well as clinical activities that make up everyday life.
The Problem: Challenges Facing Multilingual Persons with Dementia
To be able to communicate with other people in meaningful ways is key for the autonomy, sense of self, identity and wellbeing of human beings. When a person is afflicted by the progressive cognitive impairment characteristic of the various dementias, their language and communication skills will be affected in different ways over the course of the illness. The gradual loss of both spoken and embodied resources, including gestures, facial expressions and body movements, can severely hamper a person's opportunities, capabilities, confidence and willingness to partake in social activities. In turn, this suite of losses can lead to social isolation, depression and, in some cases, the acceleration of cognitive decline. Clearly, it is of paramount importance to intervene in this communicative and psychological cascade in whatever way possible. Research in this area in recent years has proactively explored a promising shift from a focus on linguistic deficits and inexorable decline to a focus on the optimization of preserved communicative resources (Davis & Guendouzi, 2013; Hydén et al., 2014; Schrauf & Müller, 2014; see also Leibing & Cohen, 2006). This new direction in research can be traced to seminal works on the language abilities of persons with dementia by Guendouzi and Müller (2006), Hamilton (1994), Ramanathan (1997) and Sabat (2001), which in turn have triggered new and promising research on the facilitative actions and practices of spouses at home, children, and staff in residential care and various healthcare settings (Davis et al., 2011; Jansson, 2014; Jansson & Plejert, 2014; Lindholm, 2008, 2015; Majlesi & Ekström, 2016; Small et al., 2015).
Nevertheless, the majority of research to date on interaction in dementia has dealt with monolingual encounters (for an excellent introduction to methods, see Guendouzi & Müller, 2006), leaving aside the pressing needs and complexities of multilingual and multicultural encounters. This is surprising, since multilingualism in most countries of the world is the rule rather than the exception (de Bot & Makoni, 2005). The twin forces of globalization and political instability in many parts of the world have triggered massive migration across cultural borders. As a result, countries that may have been relatively ethnoculturally homogeneous are becoming increasingly diverse. In these countries, the number of ageing immigrants is rapidly multiplying, and health centres, hospitals and residential care facilities are experiencing a sudden and dramatic rise in numbers of patients and clients from culturally and linguistically diverse backgrounds. Similarly, in many of the world's already ethnoculturally diverse countries there are ageing populations that often lack access to healthcare in their native languages. Given that age is the major risk factor for Alzheimer's and other dementias, it is not surprising that a significant number of these older persons will also be affected by cognitive decline and dementia, which (again) has serious consequences for their abilities to communicate. In addition, globalization and immigration have occasioned an ethnoculturally diverse workforce within the care and healthcare sector. Whereas this diversity is primarily a great asset (e.g. Jansson, 2014), it nonetheless adds further to the complexity of social interaction in healthcare encounters and other settings of significance for the maintenance of quality of life for multilingual people with dementia.
As with monolinguals, multilingual persons with dementia also experience a gradual loss of their language and communicative abilities. In contrast to monolinguals, however, multilingual persons are more likely to experience social encounters with caregivers, or clinical staff with whom they share very limited or no verbal language at all. This may pose challenges for the establishment of mutual understanding, and for building rapport and trustful relationships. However, as will be demonstrated in this book, the detailed scrutiny of interlocutors' embodied actions and utilization of prosodic resources also reveals the subtle means by which affiliation can be expressed despite limitations in a shared spoken language (Small et al., this volume; Yazdanpanah & Plejert, this volume). The importance of increased awareness of interactional strategies that may be described as embodied will be returned to in the final chapter, where the practical implications and applications of the chapters are discussed further.
Previous Research: Studies on Multilingualism and Ageing/Ethnicity and Dementia
Even within the larger literature on dementia in cognitive, neurological and psycholinguistic domains there are few studies of multilingual persons with dementia, and what few there are deal primarily with multilingualism and ageing more generally (e.g. de Bot & Makoni, 2005; Schmid & Lowie, 2011, particularly parts II and III), potential cognitive benefits of multilingualism in relation to dementia (e.g. the seminal work by Bialystok et al., 2007, 2014; Luk et al., 2011), or are concerned with matters of language attrition and reversion to first (L1) and second languages (L2) over the lifespan (e.g. de Bot & Weltens, 1995; Paradis, 2007; Schmid, 2009, to mention a few). In addition to these cognitively oriented approaches, there is developing research on ethnicity and dementia that speaks obliquely to the situation of multilinguals. For instance, the volume edited by Yeo and Gallagher-Thompson (2006) addresses the specificities of dementia in relation to certain ethnic groups (e.g. American Indian, African American, Asian Indian American, Hispanics, and so on), both in terms of epidemiology and dementia assessments and in discussions on family caregiving and services. However, although informative and important, these studies do not emphasize the actual practices and actions that prevail in real everyday multilingual encounters involving people with dementia, their next of kin, staff and clinicians, in the focus of the current volume.
Three Extant Literatures on Multilingual Interaction and Dementia
Very little is known about multilingual interaction and dementia in which detailed analyses are made of interlocutors' efforts to achieve mutual understanding. There are some tantalizing exceptions, however, and we have collected these literatures in three categories for brief review below. First, there are several studies that in different ways approach issues around codeswitching, including language loss, language choice and language separation in multilingual people with dementia, Secondly, there are studies concerning the challenges (and dangers) of administering neurocognitive assessment instruments with patients who have limited literacy, and/or do not speak the languages of the clinicians administering them. Thirdly, there are a handful of studies on multilingual encounters between caregivers and residents with dementia in residential care. This research addresses the challenges facing multilingual persons with dementia, their families, and staff in short- or long-term care units. In particular, some studies investigate interaction within ethnoculturally profiled residential care, i.e. facilities where staff speak the same language as the residents, and where the environment, food, and so on have been culturally adapted in various ways to their dwellers. It should be noticed that many of the scholars involved in this prior work are also contributors to the present volume.
Codeswitching in dementia
Among the studies that have focused on spoken language and interaction involving multilingual persons with dementia, there are investigations of language choice and language separation, often with a particular emphasis on patterns of codeswitching (Albert & Obler, 1978; Hyltenstam, 1995; Hyltenstam & Stroud, 1989, 1993; Luderus, 1995). Codeswitching may be defined as the 'alternating use of two or more "codes" within one conversational episode' (Auer, 1998: 1), and may concern anything from the insertion of a single word from one language into a stretch of talk in another language, to mixing phrases and multiple speaking-turns in different languages (Auer, 1998). The notion of codeswitching is far from uncomplicated, even in healthy multilingual populations, and more so when it comes to persons with dementia or other conditions that affect language skills. This is because for many multilinguals, alternating between languages may be a common, or even default manner of interacting.
The situation is even more complex when we consider multilinguals who experience cognitive decline. de Bot and Makoni (2005: 66) note that in many studies: 'information on switching behaviours before the onset of cognitive decline are more often than not absent, as is information on patterns of CS [Codeswitching] in the communities the patients come from'. In addition, data on the individual's current language habits, such as accounts given in interviews or self-reports obtained in questionnaires, may not reliably reflect what participants can actually do in interaction, but rather what they experience or wish that they could do. To distinguish a person's ordinary and typical codeswitching practices from pathological ones is therefore a great challenge. Ideally, data in the form of recordings of interaction collected before dementia onset combined with self-reports would be required in order to be able to empirically establish to what extent codeswitching patterns after onset are related or not to cognitive decline.
Investigators have dealt with these challenges in a variety of ways. For example, Hyltenstam and Stroud (1993) reported on a study on codeswitching in people with dementia whose mother tongue was Finnish, but who had been proficient and active speakers of Swedish L2 during large parts of their lives. Participants were interviewed by a Swedish monolingual and a Finnish interviewer, the latter, however, also being a speaker of Swedish. It turned out that four out of the six persons with dementia were not able to adapt adequately to the language of the monolingual Swedish interviewer. In effect, despite being addressed only in Swedish, they were unable to respond in Swedish, but rather responded in Finnish. Codeswitching patterns that occurred in the interactions with the Finnish interviewer were, however, more difficult to evaluate, since the use of either Finnish or Swedish could be considered appropriate since '... the Finnish interaction could quite reasonably be interpreted as a bilingual speech situation' (Hyltenstam & Stroud, 1993: 232; see also Lindholm, this volume, for a similar language situation).
Friedland and Miller (1999) were critical of the work by Hyltenstam and Stroud (1989) and Luderus (1995) for applying a priori terms such as language choice and language separation on interaction in a top-down manner. In contrast, they utilized conversation analysis (CA) in a study of four bilingual speakers (English-Afrikaans) with dementia. In particular, they stressed that the issue of whether a speaker had difficulties choosing a language or separating his or her languages could only be assessed by taking into account the local, sequential environment of each instance of codeswitching. How codeswitching was responded to, for example in terms of repair initiation, and whether the speaker with dementia would be able to conduct repair were highlighted. Of main importance was the fact that the bottom-up approach offered by use of CA facilitated the establishment of whether or not an instance of codeswitching made sense to participants themselves, i.e. in being treated as either appropriate or non-appropriate at a certain point of talk. The work by Friedland and Miller (1999) is of particular relevance to the present volume, since they offer an early CA-contribution to the study of multilingual interaction and dementia. Codeswitching practices as interactional resources are highlighted particularly in the chapters by Lindholm (Chapter 2) and Müller (Chapter 3), both of whom demonstrate how the choice of language, as well as talk about a specific language, are important features of people's identity and a natural part of everyday interactional practices in multilingual older people's care. In addition, it is shown how staff adapt to the language choice of residents or their assumed preferences (when possible), for example, relating to knowledge about the residents' language habits prior to moving into residential care (Lindholm, this volume).
A central theme of this book is, of course, how different languages are used in encounters that involve a multilingual person with dementia. Similarly to the approach adopted by Friedland and Miller (1999), the interactional consequences of language use are crucial and a main concern of all contributions.
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Excerpted from Multilingual Interaction and Dementia by Charlotta Plejert, Camilla Lindholm, Robert W. Schrauf. Copyright © 2017 Charlotta Plejert, Camilla Lindholm, Robert W. Schrauf. Excerpted by permission of Multilingual Matters.
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