thirty bilingual ( english - malayalam ) individuals ( 16 males and 14 females ) diagnosed with alzheimer 's disease in the age range of 65 - 88 years ( mean 77.4 , sd 6.6 ) participated in the study . participants were diagnosed by a medical team including a neurologist , a neuropsychiatrist and experts in geriatrics . on the day of data collection , participants were assessed using the mini - mental state examination   and clinical dementia rating ( cdr ) scale . based on the cdr scores , participants were grouped into mild ( n = 9 ) , moderate ( n = 12 ) and severe ( n = 9 ) degree of dementia . individuals with evidence for other neurological disorders such as traumatic brain injury , stroke , hydrocephalus , and encephalopathy as well as psychiatric disorders such as major depression or schizophrenia were excluded from participation . the study did not include any invasive procedures , and all procedures were strictly adhered to ethical considerations . asha facs addresses functional communication across four domains : social communication ; communication of basic needs ; reading , writing , number concepts , and daily planning . measurement of the 43 functional communication items is based on a 7-point scale , where 1 = does not do , 2 = needs constant assistance to perform a communicative behaviour , 3 = needs assistance very frequently , 4 = needs moderate assistance , 5 = needs assistance occasionally , 6 = rarely needs assistance , and 7 = totally independent to perform the communication behaviour . information about the 43 items was obtained by direct observation , client and caretaker reporting . although it is a general tool to assess the functional communication in adults , some studies attempted to classify the functional communication of adults with neurogenic disorders . hughes and orange   tried to profile functional communication in traumatic brain injury into the who icf framework by mapping the asha facs items . the current study made a similar attempt in the dat population by using asha facs as a tool to link with the various subdomains of the icf framework . each item in asha facs was linked to the icf framework by assigning an icf code . judge a was involved in the field testing phase of the icf in india and had 10 years of work experience with the icf , and judge b had 4 years of practical experience with the framework . interrater agreement was statistically verified by using cohen 's kappa (  = 0.72 ) . the severity rating scales used ( cdr and the mini - mental state examination ) were capable of addressing the impairment and severity of various body functions which are related to dat . therefore , the current study excluded the body structures and function component from its main goal . all 43 asha facs items matched with the components under  functioning and  disability. codes were selected from the various subdomains of the activity and participation domain . selected icf domains were communication , learning and applying knowledge , interpersonal interactions and relationship , major life areas , domestic life and general task demands . thirty - two of the 43 asha facs items were linked to various items under a communication subdomain . five additional items were also added from icf subdomains such as domestic life ( d6200 ) , interpersonal interactions and relationships ( d7104 , d7701 ) , domestic life ( d6600 ) as well as community , social , and civic life ( d9205 ) . to address the specific communication barriers in environment , two items from the environment component of the icf were also included . codes under the environment domain were added from the products and technology subsection ( e1250 ) and the support and relationship subdomain ( e310/e340 ) . all 50 items ( asha facs + icf ) were identified as applicable to alzheimer 's disease by five speech language pathologists with 6 years of experience . interrater reliability was checked by using the weighted kappa analysis ( w = 7.4 ) . thirty bilingual ( english - malayalam ) individuals ( 16 males and 14 females ) diagnosed with alzheimer 's disease in the age range of 65 - 88 years ( mean 77.4 , sd 6.6 ) participated in the study . participants were diagnosed by a medical team including a neurologist , a neuropsychiatrist and experts in geriatrics . on the day of data collection , participants were assessed using the mini - mental state examination   and clinical dementia rating ( cdr ) scale . based on the cdr scores , participants were grouped into mild ( n = 9 ) , moderate ( n = 12 ) and severe ( n = 9 ) degree of dementia . individuals with evidence for other neurological disorders such as traumatic brain injury , stroke , hydrocephalus , and encephalopathy as well as psychiatric disorders such as major depression or schizophrenia were excluded from participation . the study did not include any invasive procedures , and all procedures were strictly adhered to ethical considerations . asha facs addresses functional communication across four domains : social communication ; communication of basic needs ; reading , writing , number concepts , and daily planning . measurement of the 43 functional communication items is based on a 7-point scale , where 1 = does not do , 2 = needs constant assistance to perform a communicative behaviour , 3 = needs assistance very frequently , 4 = needs moderate assistance , 5 = needs assistance occasionally , 6 = rarely needs assistance , and 7 = totally independent to perform the communication behaviour . information about the 43 items was obtained by direct observation , client and caretaker reporting . the scale can be administered in approximately 20 min . although it is a general tool to assess the functional communication in adults , some studies attempted to classify the functional communication of adults with neurogenic disorders . hughes and orange   tried to profile functional communication in traumatic brain injury into the who icf framework by mapping the asha facs items . the current study made a similar attempt in the dat population by using asha facs as a tool to link with the various subdomains of the icf framework . each item in asha facs was linked to the icf framework by assigning an icf code . linking judge a was involved in the field testing phase of the icf in india and had 10 years of work experience with the icf , and judge b had 4 years of practical experience with the framework . interrater agreement was statistically verified by using cohen 's kappa (  = 0.72 ) . the severity rating scales used ( cdr and the mini - mental state examination ) were capable of addressing the impairment and severity of various body functions which are related to dat . therefore , the current study excluded the body structures and function component from its main goal . all 43 asha facs items matched with the components under  functioning and  disability. codes were selected from the various subdomains of the activity and participation domain . selected icf domains were communication , learning and applying knowledge , interpersonal interactions and relationship , major life areas , domestic life and general task demands . thirty - two of the 43 asha facs items were linked to various items under a communication subdomain . five additional items were also added from icf subdomains such as domestic life ( d6200 ) , interpersonal interactions and relationships ( d7104 , d7701 ) , domestic life ( d6600 ) as well as community , social , and civic life ( d9205 ) . to address the specific communication barriers in environment , two items from the environment component of the icf were also included . codes under the environment domain were added from the products and technology subsection ( e1250 ) and the support and relationship subdomain ( e310/e340 ) . all 50 items ( asha facs + icf ) were identified as applicable to alzheimer 's disease by five speech language pathologists with 6 years of experience . interrater reliability was checked by using the weighted kappa analysis ( w = 7.4 ) . thirty bilingual participants ( english - malayalam ) aged 65 - 88 years ( 16 males and 14 females ) who met the selection criteria and whose responses ( including caretaker ) to the questionnaire were complete in all aspects were analysed . table 1 shows the distribution of the number of participants with various levels of activity limitations and participation restrictions . it can be seen in table 1 that 10 individuals had moderate issues in the communication component and 20 individuals had severe issues . in the subdomain of learning and applying knowledge , 3 individuals had mild issues , 8 had moderate issues and 19 had severe issues . in the interpersonal interactions and relationship domain , 5 participants had mild level problems , 10 had moderate level issues and 15 had severe level issues . two individuals had mild level issues in the major life areas subdomain , 7 had moderate level issues and 21 had severe issues . participants in the subdomain of domestic life had issues ranging from mild to severe levels . sixteen participants had severe difficulties , 9 had moderate difficulties and 5 had mild difficulties . the kruskal - wallis test results revealed that there is no significant difference (  = 3.599 , p = 0.165 ) between the mild , moderate and severe dat groups in the activity and participation components of the icf . results are suggestive of an equal impact on the icf activity and participation domain , irrespective of the severity of dat ( table 2 ) . the comparison of three groups on the environmental component revealed a significant difference in the kruskal - wallis test (  = 7.621 , p = 0.022 ) ( table 3 ) . since the kruskal - wallis test showed a significant difference , a post hoc evaluation was carried out by tukey 's hsd test . multiple comparison by post hoc analysis revealed a significant mean difference between mild and severe dat groups ( p = 0.011 ) on the environment component of the icf . at the same time , multiple comparison indicated that there was no significant difference between the mild and moderate dat groups ( p = 0.140 ) as well as in the moderate and severe groups ( p = 0.351 ) ( table 4 ) . the kruskal - wallis test results revealed that there is no significant difference (  = 3.599 , p = 0.165 ) between the mild , moderate and severe dat groups in the activity and participation components of the icf . results are suggestive of an equal impact on the icf activity and participation domain , irrespective of the severity of dat ( table 2 ) . the comparison of three groups on the environmental component revealed a significant difference in the kruskal - wallis test (  = 7.621 , p = 0.022 ) ( table 3 ) . since the kruskal - wallis test showed a significant difference , a post hoc evaluation was carried out by tukey 's hsd test . multiple comparison by post hoc analysis revealed a significant mean difference between mild and severe dat groups ( p = 0.011 ) on the environment component of the icf . at the same time , multiple comparison indicated that there was no significant difference between the mild and moderate dat groups ( p = 0.140 ) as well as in the moderate and severe groups ( p = 0.351 ) ( table 4 ) . activity limitations and participation restrictions due to impairment in body functions and structure are highlighted as major criteria for the diagnosis of dementia . memory and other cognitive impairments result in marked problems with social and occupational functioning . as a result of the interaction between the impairments of dat and contextual factors , all individuals with dat experience communication - related activity limitations and participation restrictions . therefore , it was crucial to study the impact of dementia on multiple functional domains of individuals . assessment of multiple domains of functions is essential to determine abilities as well as potential goals and outcomes of intervention programs . hence , the current study included 48 items under various subdomains of activity and participation components of the icf . it addressed communication - related activity limitation and participation restrictions under various subdomains such as communication , learning and applying knowledge , interpersonal interactions and relationship , major life areas , domestic life , general task demands as well as community , social , and civic life . the results of the present study revealed that there was no significant difference across the mild , moderate and severe dat groups on the activity and participation component of the icf . hence , it can be inferred from the current study that the severity of dementia is not a factor that predicts the functionality of the individual . in other words , even a mild degree of dementia can cause severe activity limitation and participation restriction in communication - related functional domains . it can be inferred from the study that the severity rating tools are insufficient enough to profile the activity limitation and participation restriction in dat . machado   investigated the influence of participation at a rehabilitation centre on the quality of life and alzheimer 's disease . they concluded that combining pharmacological treatment with psychosocial intervention might prove to be an effective strategy to enhance the quality of life of persons with dat . therefore , the current study highlights the utility of the icf framework in documentation of activity limitations and participation restrictions to set therapy goals of persons with dat . post hoc analysis by tukey 's hsd multiple comparison revealed that there is a significant difference in the environmental barriers for communication across the mild , moderate and severe dat groups . the mean difference suggested a continuum across the three different groups ( mild < moderate < severe ) . the results are suggestive of minimal environmental barriers for the mild group when compared to the moderate and severe groups . this finding was consistent with those observations which indicated that persons with mild dat benefit from strategies to improve memory , and they continue to live relatively independent lives with a minimum of assistance . however , support from the caregiver or family members was minimal for communication enhancement . byrne and orange   identified caregivers lack of knowledge about how to communicate with older adults with dat as the major barrier to optimize functioning . in the present study , this can also be a major reason for the reported environmental barriers in functional communication . family members and caregivers were not aware of the various communication strategies that could be used in persons with dat . .   emphasized caregiver education as a part of the evidence - based practice recommendations for dementia . robinson et al .   found that inclusion of multiple caregivers in cognitive behavioural therapy for treating anxiety in persons with dementia is feasible and may be beneficial in maximizing treatment gains and increasing the family 's participation in therapy . caregiver - focused intervention is essential for the effective incorporation of communication strategies in the various phases of alzheimer 's disease . thus , the current study emphasizes the need for educating the caregivers to become a facilitator in functional communication . according to kinsella and phillips , individuals with dementia - associated communication problems the most common dementia - associated diseases are progressive in nature and in need of appropriate services that will benefit the individual and maximize cognitive - communication functioning at all stages of the disease process . the current study attempted to profile the communication - related activity limitations , participation restrictions and environmental barriers in persons with dat . it highlighted the implication of the icf in profiling the overall functionality of the individuals with dat irrespective of the severity of the disorder . this study has implications for making a management plan oriented towards functionality of persons with dat . the study will have implications for deciding the occupational status ( back to work or continuing in work ) of persons with dementia . the asha   mandates the role of the speech language pathologist in the identification , assessment , intervention , counselling , collaboration , case management , education , advocacy and research of persons with dat . since the current study focused on the overall functionality of the individual , it will be useful for the speech language pathologists to address the specific goals in the dat population on a broader perspective . even though we did not address the outcome measurement , future studies can focus on the utility of a similar framework to document the functionality before and after treatment . future studies extending the same methods for other adult communication disorders should also be conducted . activity limitations and participation restrictions due to impairment in body functions and structure are highlighted as major criteria for the diagnosis of dementia . memory and other cognitive impairments result in marked problems with social and occupational functioning . as a result of the interaction between the impairments of dat and contextual factors , all individuals with dat experience communication - related activity limitations and participation restrictions . therefore , it was crucial to study the impact of dementia on multiple functional domains of individuals . assessment of multiple domains of functions is essential to determine abilities as well as potential goals and outcomes of intervention programs . hence , the current study included 48 items under various subdomains of activity and participation components of the icf . it addressed communication - related activity limitation and participation restrictions under various subdomains such as communication , learning and applying knowledge , interpersonal interactions and relationship , major life areas , domestic life , general task demands as well as community , social , and civic life . the results of the present study revealed that there was no significant difference across the mild , moderate and severe dat groups on the activity and participation component of the icf . hence , it can be inferred from the current study that the severity of dementia is not a factor that predicts the functionality of the individual . in other words , even a mild degree of dementia can cause severe activity limitation and participation restriction in communication - related functional domains . it can be inferred from the study that the severity rating tools are insufficient enough to profile the activity limitation and participation restriction in dat . machado   investigated the influence of participation at a rehabilitation centre on the quality of life and alzheimer 's disease . they concluded that combining pharmacological treatment with psychosocial intervention might prove to be an effective strategy to enhance the quality of life of persons with dat . therefore , the current study highlights the utility of the icf framework in documentation of activity limitations and participation restrictions to set therapy goals of persons with dat . post hoc analysis by tukey 's hsd multiple comparison revealed that there is a significant difference in the environmental barriers for communication across the mild , moderate and severe dat groups . the mean difference suggested a continuum across the three different groups ( mild < moderate < severe ) . the results are suggestive of minimal environmental barriers for the mild group when compared to the moderate and severe groups . this finding was consistent with those observations which indicated that persons with mild dat benefit from strategies to improve memory , and they continue to live relatively independent lives with a minimum of assistance . however , support from the caregiver or family members was minimal for communication enhancement . byrne and orange   identified caregivers lack of knowledge about how to communicate with older adults with dat as the major barrier to optimize functioning . in the present study , this can also be a major reason for the reported environmental barriers in functional communication . family members and caregivers were not aware of the various communication strategies that could be used in persons with dat . .   emphasized caregiver education as a part of the evidence - based practice recommendations for dementia . robinson et al .   found that inclusion of multiple caregivers in cognitive behavioural therapy for treating anxiety in persons with dementia is feasible and may be beneficial in maximizing treatment gains and increasing the family 's participation in therapy . caregiver - focused intervention is essential for the effective incorporation of communication strategies in the various phases of alzheimer 's disease . thus , the current study emphasizes the need for educating the caregivers to become a facilitator in functional communication . according to kinsella and phillips , individuals with dementia - associated communication problems are the fastest growing clinical population . the most common dementia - associated diseases are progressive in nature and in need of appropriate services that will benefit the individual and maximize cognitive - communication functioning at all stages of the disease process . the current study attempted to profile the communication - related activity limitations , participation restrictions and environmental barriers in persons with dat . it highlighted the implication of the icf in profiling the overall functionality of the individuals with dat irrespective of the severity of the disorder . this study has implications for making a management plan oriented towards functionality of persons with dat . the study will have implications for deciding the occupational status ( back to work or continuing in work ) of persons with dementia . the asha   mandates the role of the speech language pathologist in the identification , assessment , intervention , counselling , collaboration , case management , education , advocacy and research of persons with dat . since the current study focused on the overall functionality of the individual , it will be useful for the speech language pathologists to address the specific goals in the dat population on a broader perspective . even though we did not address the outcome measurement , future studies can focus on the utility of a similar framework to document the functionality before and after treatment . future studies extending the same methods for other adult communication disorders should also be conducted . the present study aimed to profile dat - based communication disorders on the icf framework and investigated the influence of the severity of dat on various icf components . additional items were also added to obtain a complete picture of communication - related functionality of the individuals . the results highlighted the unique feature of the icf in profiling the activity limitations and participation restrictions of persons with dat irrespective of the severity . it also indicated a need for modification of the communication environment and caregiver - oriented intervention for persons with dat . thus , the interactive icf model is highly useful for profiling a multifaceted condition like dat in an individualized and personalized way . the study has implication for facilitating communication - related quality of life in dat population .
purposedementia of alzheimer 's type ( dat ) is a major cognitive communication disorder . 
 the present study attempted to analyse communication disorders in dat in the international classification of functions ( icf ) framework . 
 the study investigated the impact of the severity of communication disorders in persons with dat on activity participation and environment components of the icf.methodthirty bilingual individuals with dat in the age range of 65 - 88 years were classified into three groups of mild , moderate and severe degree of dementia . 
 forty - three items of the american speech - language - hearing association functional assessment of communication skills for adults ( asha facs ) were linked to the icf framework . 
 a few additional items were also added for a complete profiling of dat . 
 a total of 50 ( asha facs + icf ) items were rated and administered for the purpose of the study.resultsthe study revealed a disproportionate impact of the severity of dat on activity participation and environment components of the icf.conclusionthe present study investigated the utility of the icf framework for profiling the functionality of persons with dat . 
 this profiling highlighted the need for ensuring effective communication and quality of life in the dat population .