This edited volume presents new research in conversation analysis (CA) on social interaction in dementia. The fourteen empirical studies powerfully demonstrate that CA, true to its methodological remit, reliably discovers and makes available for scrutiny the subtle, micro-level, linguistic behaviors and resources by which people with dementia, their caregivers, and their providers manage and negotiate remembering and progressive forgetting while also pursuing meaningful activities and tasks.
The implicit promise of the project is that, given an incisive analysis of dementia interaction, it becomes possible to create carefully targeted interventions, pedagogically enriched trainings, and a more holistic account of dementia that would encourage, enliven, and extend dementia communication. Thus, the volume is more or less a balance between analytic pieces and applications.
What are the advances? What are the applications? And ultimately, what is the vision that pervades the collection? Although the editors collect the fourteen studies under four themes (diagnostics, conversational strategies, epistemics, and communication challenges), I take the liberty of re-ordering and re-grouping some chapters to address these questions, and for each question I discuss several, but not all chapters.
Advances: Epistemics and deontics. Not surprisingly, the intense development of epistemics in CA over the past couple of decades (Heritage Reference Heritage, Sidnell and Stivers2013), and the more recent methodological attention to deontics (Stevanovic & Peräkylä Reference Stevanovic and Peräkylä2014), are the primary drivers of new findings in the CA of dementia talk. Epistemics is about interactionally managing knowledge, memory, and (crucially for dementia) forgetting. Deontics is about managing what-to-do or what-should-be-done, who gets to decide or do, and who must comply, all of which (especially in the case of dementia) is conditioned by marked differences in epistemic status. Five of the studies (chapters 7–11) trade heavily in these frameworks.
A prime example at the intersection of epistemics and deontics is the case of a man with dementia who tussles with his caregiver about just when and where a tube of dental paste appeared in the kitchen. In this study (chapter 8), Anne Marie Dalby Landmark & Jan Svennevig explore how the man uses ‘first actions’ (first turns in adjacency pairs) to articulate and control conversational topics (deontics), and how he repeats knowledge claims to challenge the epistemic primacy of the caregiver’s assertions.
Two further pieces show how remembering is interactionally negotiated by and distributed across interlocutors. Lyndsay M. Lindley (chapter 11) explores a case in which an older woman with dementia, a former waitress, is invited to give job advice to her granddaughter, a newly hired waitress. The grandmother demonstrates epistemic authority and confidently crafts her advice. However, as the conversation proceeds, she shifts to interactionally ‘doing remembering’ via strategic laughs, interjections, and non-verbal alignments.
Similarly, Peter Muntigl & Stephanie Hödl (chapter 9) examine an activity in which a woman with frontotemporal dementia is asked by her adult children to identify family members in photographs. Although the mother has epistemic authority (right to know) and epistemic responsibility (personal experience), she shifts the task to others by taking stances of not knowing (guesses, claims of ignorance, and disengagement). Her adult children then employ ‘response pursuits’ (hints, encouragement, and directives) to encourage her remembering.
Of note, there is a very curious interaction in which the caregiver seems to take on nearly all of the interactional task of remembering. In chapter 10, Anna Ekström, Elin Nilsson, & Ali Reza Majlesi report an interview in which the wife of a man with dementia tells a story about him in his presence, thereby treating him as a ratified hearer of his own story — to which, in principle he has privileged epistemic authority and responsibility. However, rather than holding him accountable for what should be his higher epistemic status, the man’s spouse adroitly uses touch, smiles, laughter, and gaze to mitigate the effects of her telling his story and in fact allows him to ask questions about his own life.
Also, in the ‘new advances’ category, are two chapters reporting quite unique, if not idiosyncratic, cases in which individuals consistently recruit formulaic phrases to foster the progressivity of their interactions. In chapter 5, Lisa Mikesell reports a longitudinal study with a man with behavioral variant fronto-temporal dementia who uses the phrase ‘now what’ to elicit caregivers’ assistance in well-defined tasks (recruitment to action). Over time, however, he uses the phrase in non-task-based environments (e.g. when he is stressed), but this only confuses his caregivers. An eminently effective resource in one set of contexts becomes a deficit when over-generalized later on.
In a fascinating study, Roy M. G. L. W. Foster (chapter 6) presents a person with vascular dementia who incorporates sung snippets of nine songs (from his youth) into his turns at talk, skillfully substituting these to fit semantic and syntactic slots. By these means, he tells jokes, gives compliments, makes complaints, and makes requests that entertain his companion and caregiver. In this case, overlearned content in long-term memory is selectively retrieved and interactionally adapted to the mood and topic of current conversation.
Applications: Informing dementia care. As noted in the introduction, several of the chapters directly address how CA findings might inform clinical care and institutional interactions. Here I collect chapters 13 and 14 under two themes.
A first theme addresses how caregivers might be sensitized to fostering progressivity in talk without making direct demands on faltering memory. Christina Samuelsson & Anna Ekström (chapter 13) studied caregivers’ use of video clips and images to trigger conversation. Results show that talk is more voluble when caregivers focus on the person’s feelings or attitudes (versus factual details), and when caregivers prioritize conversation over the software-driven serial presentation of images or videos.
A second theme is helping caregivers to reframe institutional tasks as social situations. In chapter 14, Camilla Lindholm & Tuula Tykkyläinen describe a communication training program in which caregivers see a three-minute clip of successful communication between a person with advanced dementia (Sarah) and a caregiver helping her with a meal. In guided reflection, caregivers worked with three prompts: (i) adding ‘speech bubbles’ to the clip, which served to normalize Sarah’s action as communicative; (ii) articulating how caregivers would communicate their tacit knowledge about helping Sarah to new staff; and (iii) re-formulations in which the guide recasts Sarah’s communicative behaviors as ‘skills’ in a ‘social situation’—this last driving home the broader lesson about ‘communication’ versus ‘task’.
Applications: Informing testing and diagnostics. Diagnostic testing and the communication of diagnosis involve highly structured institutional talk in formal settings (chapters 2–4). Testing seems especially distant from everyday conversation because standardized instruments usually require rigid adherence to item wording. Two chapters explore some variations.
Danielle Jones, Clare Jackson, & Ray Wilkinson (chapter 2) observed that clinicians sometimes adapted (recipient-designed) instructions and the presentations of test items to enhance the testee’s understanding/receipt of those items. The authors find that these adaptations reflected the clinician’s initial impressions of patient abilities.
In chapter 4, Charlotta Plejert examined the case of an interpreter-mediated cognitive assessment in which the interpreter was asked to translate a standardized instrument prima vista ‘on sight’. Inspection of the data revealed lengthy and complex repair sequences around the linguistic and cultural equivalence and comprehensibility of items for both tester and testee. Interestingly, Plejert goes on to report how these results were used to inform clinical practice. The researchers used video clips from the data in workshops with clinicians to demonstrate the complexity of the interpreter role and value of pre- and post-sessions with interpreters.
Vision: Interdisciplinary collaborations and broader networks. Finally, beyond these clinical and institutional applications, the volume also broaches the wider program of positioning and packaging CA findings, not only to make contributions to dementia communication, but to play a more integrated and systematic role in multidisciplinary clinical, public health, and basic science spaces. In this regard, Plejert’s chapter 4 is the most explicitly visionary in the volume. We saw in the previous paragraph how her research on interpreter-mediated neurocognitive testing was used in clinical training and in scientific presentations in wider dementia networks. In fact, however, the entire chapter is framed as a programmatically focused case study in ‘applied CA’ or ‘interventionist CA’, and effectively lays out a map of how CA research can be purposefully planned and conducted to make specific contributions to ongoing multidisciplinary projects and conversations in dementia research.
In a related way, Jones frames her chapter 12 as a contribution to cognitive science. Her study of telephone calls between a woman in a care home and her daughter and son-in-law over the period of a year examined patterns of memory loss both within and between calls. These observed patterns fill out at a behavioral level the picture of progressive memory tracked by cognitive scientists. Jones describes it thus: ‘I’m using excerpts to illustrate possible cognitive decline, privileging content over structure, for what it can tell us about states of brain functionality’.
In sum, the volume reports innovative research applying the epistemics and deontics frameworks to interactional remembering and forgetting in a variety of dementias. Several chapters describe the direct translation of CA research in caregiver training programs and in caregiving activities. Finally, the volume as a whole makes a case for the systematic inclusion of CA research in the larger world of clinical, public health, and social disciplines addressing dementia care. Reading the whole volume gives one the sense of a compelling research program, and excerpt after excerpt conveys that intriguing ‘aha’ experience.
