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This chapter addresses the (pragmatic) language and communication difficulties of adults who are in prison. While there are no systematic studies of speech, language and communication difficulties in adult prisoners, conditions which are strongly associated with communication difficulties such as dementia, learning difficulties and psychiatric conditions are shown to be prevalent in this population. In addition, low levels of education and literacy difficulties are frequently revealed in studies of adult prison populations. By contrast, there is far better recognition of the communication needs of foreign national prisoners. Many of the communication difficulties that are specific to the prison environment for foreign national prisoners apply equally to a home language speaker who has speech, language or communication difficulties. These difficulties are detrimental to the individual and may also reduce the effectiveness of the prison regime given that most assessment and treatment to prevent re-offending is verbally mediated. Risk assessment relies particularly on effective communication with the prisoner. If communication difficulties prevent full disclosure of risk factors, risk assessment will be of limited value and may affect not only the person but also staff and other inmates. The chapter highlights many areas where further research into adult offenders is needed and presents a policy agenda to improve health care provision for older prisoners.

Young offenders disproportionately present with Developmental Language Disorder and are likely to struggle with the communication demands of the justice system. Professional guidance outlines strategies for facilitating successful communication, but it is unknown to what extent recommendations are substantiated by evidence. This review mapped academic and grey literature regarding the communication requirements, barriers and recommendations for routine youth justice interactions, such as forensic interview and courtroom testimony. Academic papers were identified through searches of five online databases, and OpenGrey, Google Scholar and organizational websites were searched to identify grey literature. 75 of 505 retrieved papers met inclusion criteria. Extracted data were presented regarding a) requirements and barriers a young person would encounter in the youth justice system, b) communication recommendations made for each stage of this journey, and c) type of evidence underlying the outlined findings. Communication barriers included exposure to unfamiliar vocabulary, repairing misunderstandings, constructing narratives and displaying the appropriate attitude. Recommendations were wide-ranging and broadly consistent, though very few had been evaluated for effectiveness. Some papers queried the practicality and effectiveness of recommendations such as rephrasing difficult terminology. A relatively small number of papers considered the views of young offenders or observed real youth justice interactions. Future research should include observational studies of real youth justice interactions to evaluate the effectiveness of widely recommended strategies. Policymakers may wish to consider concerns raised that rephrasing the language used in the youth justice system is not practical or sufficiently effective, and that broader changes to the communication environment are required.

Background: Knowledge of the discourse performance of non‐brain‐damaged individuals is critical not only for its differentiation from disordered expression but also for more accurate models of ageing and communication. The effect of ageing and cognitive skills on the cohesive adequacy of discourse has, until now, presented a confusing and ambiguous picture. Aims: To examine comprehensively the effects of both age and cognitive skills on the discourse cohesion of 32 non‐brain‐damaged males divided into four age groups. Methods & Procedures: A large body of narrative and procedural samples (394 samples) was elicited from the participants. Their cognitive skills were determined using three tests, whilst their discourse cohesion was analyzed and correlated with the cognitive test results. Outcomes & Results: This extensive investigation of ageing effects on discourse cohesion and their relationship to cognitive behaviour did not provide neat generalizable results. It showed that ageing significantly increases the number of cohesive errors and reduces the quantity of referential ties in picture‐sequence narratives. The changes with age were limited to two aspects of cohesion and not linear across age groups. The participants’ cognitive skills declined with age. Correlations between some cognitive tests and certain cohesive changes suggest co‐occurring deficits rather than a causal explanation of cohesive decline with age. Conclusions & Implications: With ageing there are increased cohesive errors and decreased referential ties, co‐occurring with declining cognitive skills. This study yields important guidance for future research, suggesting that picture‐sequence narrative is the most effective tool for clinical evaluation of discourse, but also that findings from one discourse sample may be misleading.

Background: At least 60% of young people in the UK who are accessing youth justice services present with speech, language and communication difficulties which are largely unrecognized. The contributing reasons for this are discussed, suggesting that early language difficulty is a risk factor for other problems such as literacy difficulties and educational failure that may increasingly put the young person at risk of offending. Opportunities for identification and remediation of language difficulties before young people reach youth justice services are also outlined. Aims: To examine language skills in a sample of children in a secure children’s home aged 11–17 years. Methods & Procedures: A sample of 118 males were routinely assessed on four Comprehensive Evaluation of Language Fundamentals (CELF) subtests and the British Picture Vocabulary Scale (BPVS). Outcomes & Results: Around 30% of the participants presented with language difficulties scoring 1.5 SD (standard deviation) below the mean on the assessments. Despite them entering the home because their vulnerability was recognized, only two participants had a previous record of language difficulties. A total of 20% of the participants had a diagnosis of mental illness, 50% had a history of drug abuse and 31% had looked-after status prior to entry to the home. Conclusions & implications: Children experiencing educational or emotional difficulties need to be routinely assessed for speech, language and communication difficulties. More population-based approaches to supporting the development of oral language skills in children and young people are also supported. Keywords: language impairment, adolescents, speech and language therapy.

While poor communication between service users and front-line staff causes many service user complaints in the British National Health Service, staff rarely reflect on the causes of these complaints. We discuss findings from an action research project with midwives which suggest that the midwives struggled to fully understand complaints from women, their partners and families particularly about restricted visiting and the locked door to the midwifery unit. They responded to individual requests to visit out of hours while maintaining the general policy of restricted visiting. In this way, the door was a gatekeeping device which allowed access to the unit within certain rules. The locked door remained a barrier to women and their families and as a result was a common source of informal complaints. We argue that the locked door and restricted visiting to the midwifery unit were forms of gatekeeping and boundary making by midwives which reveals a tension between their espoused woman-centred care and contemporary midwifery practice which is increasingly constrained by institutional values.

Background\ud \ud While the prevalence of language and communication difficulties among young people in custody is well established, holistic understanding of the complexity and co-occurrence of additional vulnerabilities among this population are rare.\ud \ud \ud Methods\ud \ud Ninety-three young people in a young offenders institution in England were assessed using the Comprehensive Health Assessment Tool, the Test of Word Knowledge, and a range of additional assessments of communication, cognition, and neurodevelopmental difficulties.\ud \ud \ud Results\ud \ud Forty-seven percent of the young people demonstrated an aspect of language skills significantly below the population average, with more than one in four identified as having impairment. Only one in four of those with an impairment had previously accessed speech and language services. Language needs were associated with difficulties with social communication and nonverbal cognition, as well as higher risk of self-harm and substance misuse.\ud \ud \ud Conclusions\ud \ud Earlier identification of language difficulties requires routine assessment of young people at risk of engagement in offending behavior. Where language difficulties are identified, holistic assessments of needs should be undertaken. There is a need for speech and language therapy provision within youth justice services, as well as in other services accessed by young people at risk of engagement in offending.

Background; With advances in medical technology, increasing numbers of patients are ‘living with’ a terminal cancer diagnosis for longer periods; this coupled with changes in government policy, is resulting in patients being treated closer to home rather than in specialist centres, bringing acute hospital physiotherapists into increasing contact with this patient group. \ud Aim; To describe the experience of acute hospital physiotherapists with palliative cancer patients. \ud Design; Semi-structured interviews analysed utilizing Colaizzi’s method of analysis, reported using the COREQ guidelines. \ud Setting; Acute Hospital in the UK. \ud Participants; The first twelve physiotherapists who volunteered for the study who met the inclusion criteria.\ud Results; Two main themes were identified, Attitudes and Issues, with four sub-themes in attitudes (terminology, physiotherapists perceptions, other professionals perceived attitudes towards physiotherapists, and patients and families perceived attitudes towards physiotherapists’): There were six sub-themes in issues (communication, education, emotions, boundaries, referring onward from the acute setting and time).\ud Conclusions and Implications for Practice; Some physiotherapists understand and apply their skills to improve the quality of life of palliative cancer patients. However, it is suggested that the majority of physiotherapists regard these patients as ‘dying from’ rather than ‘living with’ a terminal cancer diagnosis. Referral protocols and service pathways are lacking. There is an opportunity to improve how the profession promotes itself to other professionals, the public and physiotherapists of the future, to facilitate palliative cancer patients’ access to rehabilitation when and where they need it, and to deliver services in line with government policy.

Background the popularity of non-prescription, over-the counter (OTC) medicines, vitamins, minerals, homoeopathic remedies and herbal supplements (CAM) has grown significantly in recent years. However, we have limited knowledge relating to why pregnant women use CAM and how this may relate to the provision of maternity care. Using an interview approach this study explored the nature of over-the-counter and complementary medicines use in a sample of pregnant women. Methods this interview study formed part of a larger self-administered questionnaire survey on the extent of CAM use in pregnancy at large NHS Trust in England. The questionnaire provided the opportunity for women to complete a contact information reply slip if they were happy for follow-up interview. Audio recorded, face to face interviews were undertaken with a sample of 10 women. Results the reasons the women who were interviewed gave for using CAM broadly fell into two areas centred essentially on the contrasting advantages of CAM and disadvantages of conventional medicine. Doctors or midwives were rarely informed about the use of CAM medicines during pregnancy. Conclusion the women saw CAM as outside of biomedicine and part of a holistic approach to health and well-being over which they are able to maintain their personal control. Non-disclosure of CAM use was common, a feature of which, appears to be some health-care professionals' lack of realisation of the importance, to women, of a holistic approach to their health, key to which is a desire to retain control over decisions associated with their well-being.

The purpose of this research was to ascertain the views of staff and managers within a youth offending team on their experiences of working with a speech and language therapist (SLT). The model of therapy provision was similar to the whole-systems approach used in schools. The impact of the service on language outcomes is reported elsewhere (Gregory and Bryan, 2011). A questionnaire was sent to all staff asking about their experiences related to working with a speech and language therapist. Eight telephone interviews were then conducted to explore the questionnaire findings further and to gain a management perspective on speech and language therapy within a youth offending service (YOS) team. Staff were largely positive about their experience of working with a SLT. Understanding the nature of the presenting communication difficulties and having strategies to manage these were linked to improvements in wider working practices, which managers linked to culture change. The whole-systems model of service delivery appeared to have potential application to youth justice contexts. Direct access to the SLT to support communication aspects of their work was particularly important to the YOS staff. Further research is needed to examine the optimum model of speech and language therapy in youth justice settings, and the potential contribution to criminal justice outcomes such as prevention of re-offending.

Hearing impairment is one of the most common sensory disabilities, affecting millions of people worldwide. The current management of acquired hearing impairment in adults is usually in the form of hearing aids. An auditory rehabilitation programme may or may not be provided although literature suggests that such programmes may enhance hearing aid benefits. This study was conducted in an Arabic-speaking country, specifically Saudi Arabia, and is the first to develop an auditory rehabilitation intervention programme in the Arabic language that focuses on working age adults who are new hearing aid users. Method: Randomised intervention study design. Thirty-five participants with mild to severe acquired hearing loss (intervention group n=18, control group n=17). Results: Significant changes were found in the performance of the intervention group in the Minimal Audible Capabilities (MAC) test, a lip reading test and the Glasgow Hearing Aid Benefit Profile (GHABP) questionnaire when compared with the control group. No significant difference was found in speech test scores between the two groups. Conclusions: A short individualised auditory rehabilitation intervention programme can yield a significant improvement in the performance of hearing impaired adults by enhancing the benefits of hearing aid use.

There have been calls for speech and language therapists (SLTs) to work within a public-health framework to support language development. Innovative practice is reported, but the range of services remains unknown. Furthermore, the potential impact of public health practice in speech and language therapy on early child development is also currently unknown. A new method in SLT research, systematic scoping reviews enable greater breadth of focus than traditional systematic reviews when identifying innovative practice.To report scope and critically appraise evidence of family-focused health-promotion practice for early language development in this area.Using the Cochrane Public Health Group scoping review framework, data from reports of health-promotion practice with families of children aged 0-3 years were extracted and critically appraised on service delivery, information, reach and evaluation.Group-based service delivery was the most popular form of service delivery. There were limited reports on the information given in services and on their reach. Questionnaires were the most popular reported evaluation method. Quality of evaluations was poor due to lack of replicability and experimental control in the studies reported.This method of systematic review has highlighted the scope of health-promotion practice in speech and language therapy and also demonstrated the lack of evidence for its effectiveness on child language development. It is argued that systematic scoping reviews are valuable for scoping innovative practice in areas where either there is a lack of robust evidence or there is a high level of heterogeneity in practice or evaluation. To support clinician appraisal of available evidence, recommendations are given for development of questionnaire appraisal and for categorization of evidence levels on summary databases.

This study examined the effects of right brain-damage (RBD) on oral discourse production using a multi-layered discourse processing model. Narrative and procedural discourse samples from participants with RBD and no brain damage were analysed in terms of seven broad areas corresponding to the processing levels of the model. Participants also completed attention, cognitive, general communication and RBD assessments. Despite their normal performance on all assessments (except those on attention), the participants with RBD demonstrated statistically significant differences in syntactic complexity, clarity disruptors and dysfluencies, as well as in discourse grammar and clausal structure in the narratives and in cohesion in the procedures. A model-based theoretical explanation accounting for the deficits noted in participants with RBD, together with clinical guidelines, is provided.

This paper discusses the implementation and evaluation of an interaction-focused intervention single case study for a couple where one partner has aphasia. Drawing on conversation analytic research, naturally occurring conversations of the couple at home pre- and post-intervention were collected and analysed. Analysis of the speaker with aphasia's topic initiating turns in the pre-intervention conversation showed that in each case a feature of the attempt was that the speaker had difficulty in getting the topic initiation accepted and established. Drawing on conversation analytic work on topic initiations in normal conversation, intervention focused on training the couple to co-produce these topic initiating turns of the speaker with aphasia in a collaborative and step-by-step manner. Post-intervention, there was evidence that the couple were now using this new method, albeit in a slightly different way to that worked on in the intervention sessions. Drawing on work into adaptation by speakers with aphasia and their conversation partners, these results are discussed in terms of a process of mutual adaptation by the couple.

Aims: Recent guidelines for the care of people with Parkinson’s disease within the British National Health Service envisage a wider role in the community for Parkinson’s specialist nurses. A national survey was conducted to explore current nurse caseloads and capacity for expansion.

Aim. The study investigated the lived experiences of older patients who had been in hospital, to explore their views on dignity and the factors which promote dignity. Background. The UK government’s new ambition for old age (New Ambition for Old Age: Next Steps in implementing the National Service Framework for Older People: A Report from Professor Ian Philip, DH) states that older people should be treated with dignity. The dignity in Care Campaign (‘Dignity in Care’Public Survey, October 2006: Report of the Survey, DH) highlighted the need to raise staff’s awareness and understanding of dignity. Design. A purposive sample of older people took part in semi- structured interviews which focussed on their recent experiences of hospital admission. Qualitative data analysis was used. Method. Ten participants aged 73–83 were interviewed by a nurse researcher at home. All of the participants had an unplanned admission and were discharged home. Results. The participants although generally satisfied with their care had strong views on dignity. The following factors had the potential to promote dignity; privacy for the body, cleanliness, independence and being able to exert control, sufficient time from staff, attitudes to older people and communication. Conclusions. This study suggests that independence and effective communication are of central importance in maintaining dignity through achieving control of their situation. The participants observed that factors such as speaking inappropriately and waiting for personal care undermined older people’s perceptions of dignity. Several participants feared for their own dignity should they have cognitive problems later in their lives. Relevance to clinical practice. Staff need to be aware that communicating in a way that conveys empathy and responds to the individual as a valued person is an important factor in maintaining dignity. Nurses on hospital wards particularly need to take measures to safeguard the dignity of older people with cognitive problems who have difficulty in making their needs known.

Respect for people with dementia and their involvement in service planning is explored, based on selected research publications and policy papers, mainly from the Department of Health and the Alzheimer's Society. This article supports the inclusion of people with dementia care in service planning as part of person‐centred care. Necessary adjustments to research methods and ethics committee procedures for gaining informed consent are discussed, as is the importance of ethical policy formation and implementation, in order to achieve person‐centred care. This will ensure a high degree of active involvement by people with dementia, enhancing self‐respect and responding to the needs of this often marginalised population.

Background:\ud The number of complaints from patients and/or carers concerning aspects of care has increased over time. Yet, in spite of a growing body of national and international literature on healthcare complaints, there is a lack of knowledge around how nurses and midwives manage informal complaints at ward level, or staff needs in relation to this.\ud \ud Aim:\ud Using an action research approach with mixed methods, four phases and four cycles, the aim was to explore informal complaints management by nurses and midwives at ward level. We discuss the action research process primarily in connection with learning and service change, drawing from the qualitative data in this paper.\ud \ud Findings:\ud The analysis of the collected qualitative data resulted in three main themes, related to the complexities of complaints and complaints management, staff support needs and the existing ambiguous complaints systems, which are hard for staff and service users to negotiate. The action research approach facilitated learning and change in participants in relation to complaints management, in the collaborating trust.\ud \ud Conclusions:\ud The extant body of research on complaints does not sufficiently recognise the complexity of complaints and informal complaints management, or the complaints systems that are in place. Needs-based staff training can help support staff to manage informal complaints more effectively.\ud Implications for practice:\ud •There needs to be recognition of the complexities involved in complaints management\ud •Complaints systems need to be clearer for the benefit of service users and staff\ud •Staff need training and support that is tailored to their needs to improve their response to complaints, leading to a better patient experience\ud •Limited interventions, informed by staff needs, can lead to change and act as a catalyst for a wider change in informal complaints management

Aim and objective To understand how nurses and midwives manage informal complaints at ward level. Background The provision of high quality, compassionate clinical nursing and midwifery is a global priority. Complaints management systems have been established within the National Health Service in the UK to improve patient experience yet little is known about effective responses to informal complaints in clinical practice by nurses and midwives. Design Collaborative action research. Methods Four phases of data collection and analysis relating to primarily one National Health Service trust during 2011–2014 including: scoping of complaints data, interviews with five service users and six key stakeholders and eight reflective discussion groups with six midwives over a period of nine months, two sessions of communications training with separate groups of midwives and one focus group with four nurses in the collaborating trust. Results Three key themes emerged from these data: multiple and domino complaints; ward staff need support; and unclear complaints systems. Conclusions Current research does not capture the complexities of complaints and the nursing and midwifery response to informal complaints. Relevance to clinical practice Robust systems are required to support clinical staff to improve their response to informal complaints and thereby improve the patient experience.

Key to successfully addressing the ongoing transitions being experienced in the care home sector is a transformation of the workforce. This is required in order to respond appropriately to the increasing dependency of older people moving into care homes. This article considers the policy framework surrounding the provision of care services in England and reviews the relevant research into the workforce and the changes needed if the sector is to meet the needs of vulnerable older people living in care homes. Building on present policy and practice, consideration is given to how this change could be achieved.

Background : The field of pragmatic impairments of verbal communication in cerebrally damaged subjects dates back almost three decades. However, a systematic investigation of pragmatic competences has never been completed in a large sample of normal adults controlling for age and education factors. Aims : We aimed to examine the effects of age and education on the main features of pragmatics of verbal communication in a large sample of normal healthy subjects. Methods & Procedures : We developed an Italian version of the Right Hemisphere Language Battery devised by Bryan (1995) and administered it to 440 normal volunteers. Ages ranged from 20 to 79 years, and education corresponded to Italian levels of education. Outcomes & Results : We found that ageing and low education influenced performance on almost all the subtests of the I-RHLB. In particular, performance dropped at 70–79 years, particularly in those with the lowest level of education. Conclusions : These results suggest that processing of the pragmatic features of verbal communication parallels the decline of other cognitive functions associated with ageing and low education that previous studies have already established.

In this paper, we reconsider some of the processes that distinguish production and comprehension. In particular, we discuss the specific forms of thinking involved in each: "thinking for speaking" and "thinking for listening" (Black & Chiat, 2000; Slobin 1996). We argue that thinking for speaking (or for any form of language output) crucially involves schematisation or "paring down" of conceptual information (Dipper, 1999) a process partly driven by the language system itself. Thinking for listening, on the other hand, involves an "enrichment" of skeletal conceptual information derived from the linguistic input, using pragmatic principles. Production and comprehension involve distinct forms of interaction between thought and language, and should not be characterised as a simple reversal of the same processes. This approach allows us to account for different patterns of production and comprehension in non-fluent aphasia, and predict some of the factors that facilitate processing for people with these languages.

This exploratory study investigates relatives' overall experiences of the critical care environment and how staff perceived these experiences. Traditionally, research in Critical Care concentrated on patients' psychological well-being or relatives' immediate needs. There is little research that addresses the relative's overall experience of events. Critical Care Units are possibly the most daunting units in hospitals. Having a family member admitted to a Critical Care Unit could qualify as a traumatic-enough stressor to induce post-traumatic stress symptoms in relatives. A convenience sample of eight relatives and five staff participated in the study. The study used qualitative methods and drew on techniques of grounded theory. While staff perceived relatives' experiences accurately; issues arose, from both staff and relatives perspective, with regard to accurate dissemination of information. Further research into the communication processes used within Critical Care Units is required in addition to developing best practice in this area.

Previous research on work after stroke has used quantitative methods and a medical model approach to identify factors that influence return to work. This study uses an inclusive, qualitative methodology (focus groups) to begin to explore stroke survivors’ own perspectives about what helps and hinders paid or voluntary work after stroke. The research was conducted in partnership with Different Strokes, a British organisation of stroke survivors. Five focus group discussions were held with 37 stroke survivors and 12 of their supporters. Data was analysed using an adapted Framework approach to identify themes within and across individuals and groups. Factors representing barriers to or enablers of work were identified in four key themes: rehabilitation process, employer agency, social structural and personal. The study found evidence of social oppression via infrastructure, institutional structures and practices, and some individuals’ attitudes. Alongside this, some supportive individuals, practices and strategies were identified.

Aim To evaluate the experiences of health-care professionals, service users and carers of service users from a UK hospice in relation to dependency assessment. Design Qualitative evaluation. Sample Purposive, convenience sample of hospice staff, patients receiving hospice services and carers of patients receiving hospice services. Methods Focus group interviews with hospice staff and carers of hospice service users. Individual interviews with patients. Results Staff felt the tool used produced inaccurate results, in part because of omissions in content. They did not perceive the data produced affected working practice, e.g. staffing levels. Patients described unobtrusive assessment and stated their needs were met. Carers reported feelings of isolation. They also described differing information and support needs from the patients. Conclusion Further research is required to improve the validity of dependency data collection. Further investigation of carer assessment is also justified.

The Comprehensive Critical Care Review published by the Government in 2000 acknowledges that patients are part of family units and critical illness has an extended impact. It outlines information that should be provided to relatives and suggests recommendations be implemented within 3-5 years. The aim of this study was to gauge an overall view of provisions available across general Intensive Care Units in England for relatives, by conducting an analysis of information available and unit policies, and to see the extent that government guidelines have been adhered to. Two hundred and ten units were approached for copies of policy documents and leaflets. There was a 56% response rate. Results were collated and analysed for basic descriptive statistics using software package SPSS version 11.5. The Gunning's Fog Index was performed on 20% of leaflets to measure readability. All leaflets measured above the recommended level. Sixteen percent of units do not have a leaflet and therefore do not comply with the Department of Health recommendations. Huge variation exists nationally over the amount and quality of information that relatives have access to and receive. Only 9% of units had an official policy on how to deal with relatives. The implications of this are discussed.

Background: There is no systematic surveys of the UK prison population, but data from several sources suggest that a significant number of prisoners might have limitations in their speech, language and communication abilities. Aim: To examine the hypothesis that compared with the general population, a significantly larger number of the prison population has speech, language and communication difficulties. Method and Procedures: A survey of 10% of the young offenders within one young offender's institution was conducted. Tests of naming, picture description, grammatical competency and comprehension were used. Outcomes and Results: Forty-three per cent of participants scored at a level significantly lower than the limits acceptable for their age on the Boston Naming Test; 73% scored significantly below the acceptable limits for their age on grammatical competency; 23% scored signifcantly below the acceptable limits for their age on language comprehension; 47% of participants received more than one rating of moderate impairment on picture description. Conclusion: It was confirmed that high levels of speech, language and communication difficulties are found among the young offender population. The implications for the management of young offender, the limitations of the study and indications for further research are discussed.

At least 60% of young people in the UK who are accessing youth justice services present with speech, language and communication difficulties which are largely unrecognized. The contributing reasons for this are discussed, suggesting that early language difficulty is a risk factor for other problems such as literacy difficulties and educational failure that may increasingly put the young person at risk of offending. Opportunities for identification and remediation of language difficulties before young people reach youth justice services are also outlined.To examine language skills in a sample of children in a secure children's home aged 11-17 years.A sample of 118 males were routinely assessed on four Comprehensive Evaluation of Language Fundamentals (CELF) subtests and the British Picture Vocabulary Scale (BPVS).Around 30% of the participants presented with language difficulties scoring 1.5 SD (standard deviation) below the mean on the assessments. Despite them entering the home because their vulnerability was recognized, only two participants had a previous record of language difficulties. A total of 20% of the participants had a diagnosis of mental illness, 50% had a history of drug abuse and 31% had looked-after status prior to entry to the home.Children experiencing educational or emotional difficulties need to be routinely assessed for speech, language and communication difficulties. More population-based approaches to supporting the development of oral language skills in children and young people are also supported.

BackgroundMultidisciplinary rehabilitation is recommended for Parkinson’s disease, but evidence suggests that benefit is not sustained.Objectives(1) Implement a specialist domiciliary rehabilitation service for people with Parkinson’s and carers. (2) Provide continuing support from trained care assistants to half receiving the rehabilitation. (3) Evaluate the clinical effectiveness of the service, and the value added by the care assistants, compared with usual care. (4) Assess the costs of the interventions. (5) Investigate the acceptability of the service. (6) Deliver guidance for commissioners.DesignPragmatic three-parallel group randomised controlled trial.SettingCommunity, county of Surrey, England, 2010–11.ParticipantsPeople with Parkinson’s, at all stages of the disease, and live-in carers.InterventionsGroups A and B received specialist rehabilitation from a multidisciplinary team (MDT) – comprising Parkinson’s nurse specialists, physiotherapists, occupational therapists, and speech and language therapists – delivered at home, tailored to individual needs, over 6 weeks (about 9 hours’ individual therapy per patient). In addition to the MDT, participants in group B received ongoing support for a further 4 months from a care assistant trained in Parkinson’s (PCA), embedded in the MDT (1 hour per week per patient). Participants in control group (C) received care as usual (no co-ordinated MDT or ongoing support).Main outcome measuresFollow-up assessments were conducted in participants’ homes at 6, 24 and 36 weeks after baseline. Primary outcomes: Self-Assessment Parkinson’s Disease Disability Scale (patients); the Modified Caregiver Strain Index (carers). Secondary outcomes included: for patients, disease-specific and generic health-related quality of life, psychological well-being, self-efficacy, mobility, falls and speech; for carers, strain, stress, health-related quality of life, psychological well-being and functioning.ResultsA total of 306 people with Parkinson’s (and 182 live-in carers) were randomised [group A,n = 102 (n = 61); group B,n = 101 (n = 60); group C,n = 103 (n = 61)], of whom 269 (155) were analysed at baseline, pilot cohort excluded. Attrition occurred at all stages. A per-protocol analysis [people with Parkinson’s,n = 227 (live-in carers,n = 125)] [group A,n = 75 (n = 45); group B,n = 69 (n = 37); group C,n = 83 (n = 43)] showed that, at the end of the MDT intervention, people with Parkinson’s in groups A and B, compared with group C, had reduced anxiety (p = 0.02); their carers had improved psychological well-being (p = 0.02). People with Parkinson’s in groups A and B also had marginally reduced disability (primary outcome,p = 0.09), and improved non-motor symptoms (p = 0.06) and health-related quality of life (p = 0.07), compared with C. There were significant differences in change scores between week 6 (end of MDT) and week 24 (end of PCA for group B) in favour of group B, owing to worsening in group A (no PCA support) in posture (p = 0.001); non-motor symptoms (p = 0.05); health-related quality of life (p = 0.07); and self-efficacy (p = 0.09). Carers in group B (vs. group A) reported a tendency for reduced strain (p = 0.06). At 36 weeks post recruitment, 3 months after the end of PCA support for group B, there were few differences between the groups. Participants reported learning about Parkinson’s, and valued individual attention. The MDT cost £833; PCA support was £600 extra, per patient (2011 Great British pounds).ConclusionsFurther research is needed into ways of sustaining benefits from rehabilitation including the use of care assistants.Study registrationCurrent Controlled Trials: ISRCTN44577970.FundingThis project was funded by the National Institute for Health Research Health Services and Delivery Research programme and the South East Coast Dementias and Neurodegenerative Disease Research Network (DeNDRoN), and the NHS South East Coast. The report will be published in full inHealth Services and Delivery Research; Vol. 2, No. 51. See the NIHR Journals Library website for further project information.

This paper describes the development of a clinically viable tool for the assessment of language and associated cognitive skills in the older population which was instigated by the SIG Psychiatry of Old Age (South of England). A series of sub-tests is described. Data from normal older people is used to establish preliminary means and lower normal limits as a guide to distinguishing performance associated with normal age-related change from performance associated with pathology. The importance of allowing for the effects of normal age-related changes on language processing is illustrated. Data from older people with pathology attending clinics and hospital departments is also presented. Quantitative and qualitative language profiling is outlined. Data analysis suggests that the Barnes Language Assessment is able to profile language skills and difficulties. Indications for further research are discussed.