Speech and Communication Disorders in Dementia: Utilisation of Therapeutic Services, Care Structures, and the Role of Speech and Language Therapy in Germany - A Health Services Analysis Based on Routine Data and Primary Data Collection

Background The number of people in Germany living with dementia is estimated to be around 1.8 million at present, and it is expected to rise. Speech and communication disorders often occur in the early stages of the disease, including word-finding difficulties, impaired sentence production, and reduced comprehension of conversations. As the disease progresses, functional communication abilities decline further, which has a substantial impact on social participation, quality of life and self-determination of those affected. Speech- and communication disorders also place a significant burden on informal caregivers and are among the most frequently unmet needs of people living with dementia. Non-pharmacological interventions, such as cognitive stimulation, cognitive training or communication training for family caregivers, are considered effective and recommended by the German S3 guideline on dementia. These interventions can be provided by various healthcare professionals, including speech and language therapists, occupational therapists, neuropsychologists, nurses, and social workers. As a discipline specialising in communication, speech and language therapy is considered to play a central role in interprofessional dementia care. Despite growing evidence, little is currently known about how speech and communication disorders are addressed in routine care, or the specific role of speech and language therapy in everyday care. This health services analysis seeks to address this gap and is theoretically informed by the Throughput Model of the health care system [1], a central framework in health services research. The model conceptualises health care systems across four interrelated levels: input, throughput, output, and outcome. Input refers to patient-related, professional, and structural resources within the health care system. Throughput focuses on organisational, professional, and therapeutic processes through which care is delivered. Output describes the concrete health care services provided, while outcome refers to the effects of care at the patient or population level. The model assumes that health outcomes are shaped by the interaction of input, throughput, and output factors and thus enables a system-oriented understanding of complex care settings. Applied to the present project, the Throughput Model provides the conceptual framework for structuring the health services analysis. The project aims to systematically describe care processes at the levels of input, throughput, and output in order to identify leverage points for improving communication-related outcomes in dementia care. Particular attention is given to the role of speech and language therapy within interprofessional care structures, reflecting the profession’s specific expertise in the assessment and treatment of speech and communication disorders. Using a multi-method approach, the health services analysis aims to (1) describe nationwide utilisation patterns of speech and language therapy and occupational therapy services among people living with dementia and (2) examine how speech and communication disorders are addressed in everyday care practice, how interprofessional collaboration is organised, which role speech and language therapy assumes within these structures, and which barriers and facilitating factors influence care delivery. Methods: The health services analysis comprises two phases combining secondary and primary data. Phase 1: Quantitative routine data analysis Phase 1 consisted of a quantitative secondary analysis of anonymised statutory health insurance claims data and has already been completed. The analysis covered an observation period from 2017 to 2022 and applied both cross-sectional and longitudinal approaches. Using a cross-sectional design, basic epidemiological characteristics of people living with dementia and mild cognitive impairment (MCI) were described, along with annual utilisation densities of speech and language therapy and occupational therapy over the observation period. In addition, a longitudinal design was applied to descriptively examine the utilisation of therapeutic services over individual follow-up periods of two and five years after first diagnosis of dementia or MCI. Furthermore, multivariable logistic regression analyses were conducted to explore factors associated with the utilisation of therapeutic services. Phase 2: Explanatory sequential mixed-methods study Phase 2 is a mixed-methods study using an explanatory sequential design and builds conceptually on the findings of the routine data analysis. It comprises a quantitative and a qualitative strand. 1. Quantitative Strand: The quantitative strand consisted of a nationwide online survey of speech and language therapists, occupational therapists, physicians, neuropsychologists, nursing professionals, and social workers. The survey focused on care practices and perceived responsibilities, prescription and referral pathways, interprofessional collaboration, and structural and organisational conditions relevant to the care of people living with dementia. Data collection was completed in December 2025. 2. Qualitative strand: The qualitative strand comprises a qualitative interview study using semi-structured interviews. These aim to explain and contextualise the quantitative findings, further delineate professional roles and areas of overlap, and identify practice-oriented approaches for improving care delivery. Data collection is planned to start in March 2026. Ethical considerations The quantitative routine data analysis in Phase 1 was conducted using fully anonymised secondary data. Phase 2 of the study, involving primary data collection from healthcare professionals, has received ethical approval prior to data collection. Expected results: This two-phase health services analysis aims to contribute to the description of care for speech and communication disorders in people living with dementia from the perspective of multiple health professions. In doing so, it will systematically address and highlight a care-relevant field that has received little research attention to date. Based on the findings, recommendations will be developed for designing interprofessional care pathways, and suggestions will be made for clarifying professional responsibilities. Ultimately, the project aims to enhance communication-related care for individuals living with dementia and to strengthen their communicative and social participation. References: [1]Schrappe, M., & Pfaff, H. (2016). Versorgungsforschung vor neuen Herausforderungen: Konsequenzen für Definition und Konzept. Das Gesundheitswesen, 78(11), 689-694.