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I pretty much specialize in working with disabled people. I also am disabled and have been on the receiving end of a lot of customer service interactions. If some of these things seem strange to even mention, know that I’m mentioning it because it’s happened to me countless times.So here are my pointers:Address the customer as you would anyone else. This may seem obvious, but a lot of people don’t do this, so I feel the need to point it out. Use the same language with a disabled customer as you would with any other customer—everything from the same tone, form of address, etc. No baby voice. No pet names. No informal pronouns with adult customers if that’s strictly reserved for children and animals in your language. No weird paternalistic body language like patting them on the head. (Yes, all of these have actually happened to me.)Put your disabled customer at the center of all their decisions about the service/product you are providing. Again, this should seem obvious because it’s how you would treat any customer, but sadly this is often not what happens in reality. This point requires extra emphasis if your customer shows up with someone else like a personal care assistant or family member, or if they are having someone else facilitate communication (like an interpreter). This point also requires extra emphasis if your customer seems in any way developmentally or intellectually disabled. They still have their own preferences and opinions and you are serving them, not their PCA/interpreter/family member. This also means that you leave decisions up to them and don’t make decisions for them. Don’t take shortcuts and decide for them because you think it will be faster or easier.Let your customer take the lead on any accommodations they may need, or may not need. For example, if your customer is low vision, they might need dimmer lighting. They might need brighter lighting. They might need larger font. They might need regular font. Only they can know what they need. So just ask them and don’t assume one way or the other. By the same token, if your customer specifies that they don’t need help with something, don’t insist. For example, some people with crutches or walkers actually have a system for getting their own door. Getting the door for them anyway can mess up their system and be unsafe.If you’re not sure, ask. For example, if you don’t know if your customer is capable of signing a form, just ask. They will let you know. They are the expert on what they are capable of doing. If you’re driving them in an Uber and you don’t know if they need to be walked to the door, just ask. If they say they don’t need help, just drop them off normally. Don’t assume what they can or cannot do. Present the option, give them full autonomy, and respect their answer.Keep the interaction professional. Don’t ask personal questions about their disability. Again, this should seem fairly obvious, but sadly it’s so common that it needs to be said. If you’re there to help them open a bank account, stick to the financials. If you work at a coffee shop, stick to the order and at most, typical small talk like “How’s your day”. Also refrain from sharing personal opinions about their disability, such as telling them you think they’re an inspiration, that you’re praying for them, or whatever.Be patient. If it seems your disabled customer does need more time to process information or to do something, take the extra time. That includes, for example needing to review the content of a form they’re signing, repeating important information that they missed or didn’t understand the first time, needing more time to communicate (through technology, an interpreter, etc.) Explain the information and check for understanding. Don’t move to the next step until you’re sure that the previous step is completed successfully. Don’t rush the process especially if it seems like your customer could be lost or confused. If they process information fine but take longer to do something like fill out a form or get changed into a gown or whatever, take the extra time. Don’t rush them.Those are the major ones that come to mind now.

The question is: what is the question? Be Happy asked, "Why does Alzheimer’s disease forget memories but not spoken language?", which seems to imply that the ability to speak is not lost even when memories are being lost. Mounia Hypatia asked, "Why does an Alzheimer's patient forget everything but his mother language?" and Mustafa Mohamed asked, "Why do people who have Alzheimer's not forget their native language?", both of which seem to imply that the patient was bilingual (or multi-lingual) and lost his non-native language(s) but not his native language (i.e., the first language the patient learned to speak as a young child.) These are not the same question Be Happy asked.We'll start with Be Happy's question, "Why does Alzheimer’s disease forget memories but not spoken language?" Provided that I've interpreted it correctly, the answer, in a nutshell, is that Alzheimer's causes changes in spoken language very early in the disease -- even in prodromal Alzheimer's and amnestic mild cognitive impairment (aMCI) patients who will subsequently progress to clinical Alzheimer's -- and that the ability to understand and communicate deteriorates steadily throughout the progression of the disease, to the point that the production and comprehension of speech are eventually completely lost.The "Four A's of Alzheimer's," i.e., the four main cognitive symptoms that every Alzheimer's patient will develop, are:• Amnesia: Amnesia is the loss of memory. There are many different types of memory systems. The well-known hallmark of Alzheimer’s disease is the gradual loss of short-term episodic memory, i.e., the ability to learn, store, and retrieve information about unique personal experiences that occur in daily life. Other types of memory include, e.g., semantic memory, prospective memory, autonomic simple classical conditioning, motoric simple classical conditioning, procedural memory, perceptual priming, conceptual priming, and working memory. Each of these depends on different parts of the brain. Some of these memory systems are also impaired in the earlier stages of Alzheimer’s, while others, such as procedural memory (cognitive and behavioral skills that operate at an automatic and unconscious level, such as riding a bicycle or playing the piano), are relatively preserved until the later stages. Unlike episodic memory, semantic memory involves factual knowledge that has been learned, but for which specific "time and place" information about the source of the original experience is typically not known, such as the features of objects (e.g., apples are often red), categories (e.g., oranges and bananas are both types of fruit), historical events, mathematical tables, and personal facts, such as one’s place and date of birth, or the names of family members. In Alzheimer’s, semantic memory, like episodic memory, may also be affected from the early stages of the disease, but episodic and semantic memory loss emerge and decline independently of each other.• Aphasia: Aphasia is difficulty in communicating using language. Language is the ability to encode ideas into words or symbols for communication to someone else, and includes speaking, understanding the speech of others, reading, writing, gesturing, and using numbers. In the early stages of typical Alzheimer's, there may be mild word-finding difficulties with occasional semantic paraphasias (i.e., semantic substitutions, such as saying aunt instead of sister), but speech remains fluent and grammatically correct. Word and object knowledge (semantic knowledge) is intact for more frequently used words and objects, but impaired for less frequently used words and objects. Comprehension is intact. Reading and/or writing may be intact or mildly impaired. With progression of the disease, patients exhibit transcortical sensory aphasia, in which there is clear anomia (impaired word recall) and comprehension is affected. In the moderate to severe stages of Alzheimer's, there is a loss of fluency, increased paraphasias (use of incorrect words as well as incorrect pronunciation), and poor comprehension; as well as increasingly impaired reading and writing skills. There is a reduction in verbal output, and in the severe stages, there may be echolalia (repetition of words or phrases said by somebody else) and verbal stereotypies (repetition of meaningless words or phrases). By mid-Stage 7, speech is completely lost.• Agnosia: Agnosia is the impairment of the brain's ability to receive or correctly understand information from the senses of hearing, smell, taste, touch and vision, even though the sensory systems themselves are functional. For example, people with Alzheimer's disease often are less able to identify smells, or understand the feeling of a full bladder. They also might not be able to recognize people as the disease progresses -- not due to memory loss, but rather as a result of the brain not being able to determine the identity of a person on the basis of the information supplied by the eyes. Initially, agnosia symptoms are infrequent and transient, but as the disease progresses, they become more and more common and debilitating.• Apraxia: Apraxia refers to the inability to perform physical tasks, despite having the desire and the physical ability to perform them. Initially, the Alzheimer’s patient will lose the ability to carry out skilled movements and gestures, such as the ability to tie shoelaces. Eventually, the patient may even lose the ability to perform naturally instinctive actions, such as swallowing.Although laymen commonly believe that the first symptom to appear is memory loss, in most Alzheimer's patients, all four core cognitive symptoms emerge at roughly the same time. Onset is so slow and insidious that they may not be recognized immediately, even by close family. However, roughly 10% of late-onset (≥65 years old) Alzheimer's patients and 30% of early-onset (<65 years old) patients have variants of Alzheimer's disease in which "non-amnestic" (non-amnesia) symptoms appear long before any memory loss is detectable. These include (1) the logopenic variant characterized by primary progressive aphasia (PPA) that emerges two years or more before the other core symptoms; (2) the posterior cortical atrophy (PCA) variant characterized by disproportionate visuospatial and visuoperceptual deficits; (3) asymmetric involvement with motor and other changes consistent with corticobasal syndrome (CBS); and (4) the behavioral/dysexecutive variant (aka frontal variant), which affects frontal regions of the brain, similar to frontotemporal dementia. An inferior parietal lobule variant of early-onset Alzheimer's commonly presents with predominant acalculia, i.e., progressive difficulty with mathematical calculations. Logopenic PPA is characterized by a slow rate of speech production, marked word-finding pauses, occasional phonological errors, and difficulty with sentence (but not single word) repetition.Aphasia is the result of damage to the brain. It is typically caused by a cerebral vascular accident (stroke), or head trauma; however, it can also be caused by a tumor, brain infection, epilepsy, or a neurodegenerative disorder such as Alzheimer's. Aphasia symptoms can range from occasional trouble finding words, to losing the ability to speak, read, and/or write. A person may have aphasia yet may have normal intelligence and memory.Individual case reports and systematic studies of case series of patients with focal neurological damage have shown that there is no absolute one-to-one correspondence of aphasia symptoms or syndromes to localization of lesions. In addition, functional studies with PET and fMRI in healthy persons show the participation in language of many regions of the brain, varying according to the linguistic task; these studies also show the activation of various brain structures along the recovery phases of aphasia after a stroke. In short, language processing depends on many neural sites linked as systems and working in concert.The specific regions and/or connections that are damaged do, however, affect the specific aspects of language processing and comprehension that are affected and the subsequent symptoms. In "non-fluent aphasia", for example, speech output is severely reduced and is limited mainly to short utterances of less than four words. Vocabulary access is limited and the formation of sounds is often laborious and clumsy. At the same time, patients with non-fluent aphasia may understand speech relatively well and be able to read, but be limited in writing. In "fluent aphasia", speaking isn't difficult; in fact, the words pour out of the mouth with ease. The problem is that the patient isn’t forming coherent words, or those words aren’t coming together into coherent sentences. Reading and writing are often severely impaired. People with "anomic aphasia" can’t find the words they want to use, particularly when trying to come up with the correct noun or verb. They get around the missing words by using many other similar words or filling in the blank spaces with vague fillers like “stuff” or “thing.” As a result their speech, while fluent in grammatical form and output, is full of vague circumlocutions and expressions of frustration. People with anomic aphasia understand speech well, and, in most cases, read adequately. Difficulty finding words is as evident in writing as in speech. "Global aphasia" is the most severe form of aphasia, and is applied to patients who can produce few recognizable words, understand little or no spoken language, and can neither read nor write. There are many other possible combinations of deficits that do not exactly fit into these main categories. Some of the components of a complex aphasia syndrome may also occur in isolation; e.g., disorders of reading (alexia) or disorders affecting both reading and writing (alexia and agraphia). Severe impairments of calculation often accompany aphasia, yet in some instances patients retain excellent calculation in spite of the loss of language.Regardless of aphasia profile, difficulties across the cognitive domains of attention, memory, and executive functioning have been identified, which can negatively affect language abilities at the phonological, morphosyntactic, lexical-semantic, pragmatic, and discourse levels. These studies are helping us understand the neurobiology of language, in which diffuse cortical and subcortical structures and distributed connectivity support language in concert with other functional processes and control mechanisms. Different neurodegenerative disorders cause different types of aphasia, due to differences in the damage they do to the brain. For a review of the characteristics of aphasia found in primary progressive aphasias (PPAs), typical Alzheimer's, amnestic Mild Cognitive Impairment (aMCI), Parkinson's Disease, dementia with Lewy bodies, Huntington's disease, and Amyotrophic Lateral Sclerosis (ALS), and the usefulness of language performance analysis in diagnosing these disorders, see:Connected Speech in Neurodegenerative Language Disorders: A ReviewBoschi V, Catricala E, Consonni M, Chesi C, Moro A, Cappa SF. Connected speech in neurodegenerative language disorders: a review. Frontiers in psychology. 2017 Mar 6;8:269.Many language impairments seen in dementia are due to extralinguistic rather than linguistic deficits. Different disorders that cause dementia can produce strikingly different aphasia symptoms. A 2008 paper reviewed the evidence that had been developed to date for the relationship between extralinguistic cognitive and language abilities in Alzheimer's disease and two variants of frontotemporal dementia, i.e., semantic dementia and primary progressive nonfluent aphasia. Decreases in executive function and memory cause sentence-level processing problems seen in all three disorders. Problems with memory and attention disrupt word finding in early and moderate Alzheimer's. Deficits in the semantic/conceptual system itself are predominantly responsible for the naming and word comprehension impairments in semantic dementia and in later-stage Alzheimer's. I've included this interesting 2008 paper, even though it is a bit outdated, because it also reviewed the (older) literature on cognitive reserve and bilingualism, raising the intriguing possibility that the use of more than one language can delay the onset of Alzheimer's. More recent studies have supported this hypothesis.Language and Dementia: Neuropsychological AspectsKempler D, Goral M. Language and dementia: Neuropsychological aspects. Annual review of applied linguistics. 2008 Mar;28:73-90.Does Bilingualism Contribute to Cognitive Reserve? Cognitive and Neural PerspectivesGuzmán-Vélez E, Tranel D. Does bilingualism contribute to cognitive reserve? Cognitive and neural perspectives. Neuropsychology. 2015 Jan;29(1):139.Many experts believe that our best chance for curing Alzheimer's is to treat it in the very earliest stages of cognitive decline, e.g., prodromal Alzheimer's or, preferably, amnestic mild cognitive impairment (aMCI). Determining the most sensitive assessment tools for detecting cognitive change is crucial not only for early identification, but also for disease monitoring in clinical trials. Language assessment is being actively studied for this application. For example, the production of "connected language" (aka "spontaneous speech", i.e., spoken language that is used in a continuous sequence, as in everyday conversations) involves the use and coordination of multiple cognitive and physiological processes. As such, connected language analysis may be sensitive to early cognitive changes, and also may yield performance-based measures that are more representative of the actual skills needed for activities of daily living than are typical standardized cognitive tests. In fact, there is some evidence that changes in connected language may be detected in true preclinical Alzheimer's, in asymptomatic individuals who carry early-onset familial Alzheimer's disease (eFAD) mutations. See, e.g.:Declines in Connected Language Are Associated with Very Early Mild Cognitive Impairment: Results from the Wisconsin Registry for Alzheimer’s PreventionMueller KD, Koscik RL, Hermann BP, Johnson SC, Turkstra LS. Declines in Connected Language Are Associated with Very Early Mild Cognitive Impairment: Results from the Wisconsin Registry for Alzheimer’s Prevention. Frontiers in aging neuroscience. 2018 Jan 9;9:437.Most studies on Alzheimer's aphasia symptoms focus on lexical-semantic competence. However, even in the stage where lexical-semantic competence is still preserved, patients could also have communication difficulties due to pragmatic disruption. "Pragmatics", i.e., language meaning in context, refers to the social rules of language for the purpose of communication. The pragmatic language domain includes (a) using language to achieve goals; (b) using information from the context to achieve these goals; and (c) using the interaction between people to initiate, maintain, and terminate conversations. There are many different aspects of pragmatics that have been studied in Alzheimer's and aMCI. For example, nonliteral language (often called ‘‘figurative’’ language) is a heterogeneous linguistic entity of speech forms that go beyond the literal meaning of the words, and requires the ability to process more than the literal meaning of an utterance to grasp the speaker’s intention in a given context. Although several definitions exist for nonliteral language, there is general consensus that metaphors, proverbs, idioms, irony, sarcasm, and metonymy are among the most important types of nonliteral language. One recent study concluded that sarcasm comprehension started to deteriorate in aged normal controls; metaphor comprehension started to deteriorate in aMCI; and both continued to deteriorate as disease progressed to clinical Alzheimer's. Metaphor and sarcasm comprehension requires contextual coherence judgment, as literal interpretation can be taken out of context. It has been proposed that, in cognitively healthy people, both the literal and the nonliteral meaning are activated concurrently, and the inappropriate meaning is inhibited by the context. However, aMCI and Alzheimer's patients have difficulty suppressing inappropriate literal interpretation. Literal interpretation of metaphor causes simple lack of comprehension. In sarcastic expression, however, the speakers say the opposite of what they mean, but the Alzheimer's patient may take what is said literally. Such social miscommunication between patients and caregivers could lead to behavioral and psychological symptoms of dementia (BPSD) in patients. Caregivers’ understanding of decreased communication abilities in patients may therefore reduce BPSD and caregiver distress.Other aspects of pragmatics that have been found to be affected in early Alzheimer's include speech intonation/prosody (e.g., the appropriate use of intonational contour, including alterations in pitch, volume and duration, to convey meaning); perseveration (the uncontrolled repetition of a particular response, such as a word, phrase, thought, or emotion, in the absence of an ongoing occasion or rationale for that behavior or emotion); coherence (the appropriate maintenance of topic in discourse); and questions, turn-taking, unsure statements, and egocentric comments. Many different cognitive domains may be involved. For example, one study on coherence, using picture descriptions within a frame analysis (with “frames” being defined as internalized knowledge structures), attributed Alzheimer's patients’ difficulties with coherence to memory deficits, attentional deficits, visual perceptual problems, disruption of internalized frame representation, and/or failure to access frame knowledge.- - - - -As for the question I believe Mounia Hypatia and Mustafa Mohamed may have been asking, "Why does an Alzheimer's patient forget everything but his mother/native language?": In a nutshell, both (all) languages will inevitably be lost, but the patterns of those losses will depend on the individual, the circumstances under which each language was acquired and subsequently used, and the underlying Alzheimer's pathology (e.g., typical Alzheimer's, the logopenic variant, or mixed Alzheimer's/vascular dementia.)Trying to find answers to this question was very frustrating. Many of the papers I found failed to differentiate between Alzheimer's and other neurodegenerative dementias, but it is well-established that the patterns in language loss can vary widely among the various disorders (as noted above). Others relied on the MMSE to determine the stage of the Alzheimer's and/or the rate of decline, which can not and should not be done. (Don't get me started...) Some reported on individuals diagnosed with mild cognitive impairment (MCI) on the basis of initial clinical symptoms as if they were early-stage Alzheimer's patients; however, fully two-thirds of MCI patients will not progress to a full-blown dementia over the course of ten or more years; a third actually revert to normal; and a significant percentage of those who do progress may develop non-Alzheimer's dementias. (Note: MCI patients studied in the Mueller et al paper above were subsequently autopsy-confirmed to have had Alzheimer's pathology.) Terminology was inconsistent; many papers referred to the native (mother) language as "L1" and second language to be acquired as "L2", while others considered the dominant language to be "L1", even if it was acquired later in life. Finally, many studies incorporated findings from papers published in the twentieth century in their analyses and conclusions; however, any study on "Alzheimer's" patients published before 2005 or so can be expected to include a fairly high percentage of patients who actually had dementia with Lewy bodies (DLB) -- even today, DLB is often misdiagnosed as Alzheimer's. Also, the role that vascular disease plays in Alzheimer's is only now beginning to be understood, but was rarely considered in any of the dozens of papers I read.The study of language processing in bilingual speakers is challenging. Many confounding factors may affect linguistic performance, including, e.g., the age at which the second language was acquired (simultaneous vs. sequential bilingualism), the manner in which it was acquired (e.g., by immersion or instruction), the usage patterns of the different languages (e.g., in which contexts the various languages were or are used — at home, at work, at school, etc), the proficiency in different modalities (speaking, reading, writing, etc.) in the languages, structural similarities or differences between the languages, and societal attitudes towards the different languages. Adding a pathological condition affecting language and communication to the picture makes it even more complex -- especially a progressive disorder such as Alzheimer's, since the stage of the disorder and the rate of decline can significantly affect the outcome. Finding homogeneous groups of bilingual speakers for research is at best challenging and often impossible. Ergo, most studies have been individual "case reports" or involved very small groups of patients. Such limited studies may or may not be relevant to other patients, even those who speak the same languages.Moreover, different types of tests may or may not pick up on initial impairments, since they may be influenced by different types of language processing. For example, even something as simple as naming performance may be influenced by many factors, including grammatical class, frequency, cognate status, and communicative task. Few studies have been conducted on naming in bilingual speakers with Alzheimer's; and so far, they have not yielded conclusive results. Some studies reported comparable impairments across the languages, e.g., in a woman with logopenic progressive aphasia (which is often a variant of Alzheimer's) who spoke English and Chinese with equal fluency; an early and highly proficient Catalan-Spanish bilingual woman with Alzheimer's; and a cross-sectional study on 26 bilinguals with mild to moderate Alzheimer's who were highly proficient in both Frisian and Dutch. Other studies have reported greater impairment in the dominant language (not necessarily the L1 of the speakers), e.g., in 29 Spanish-English bilinguals with probable Alzheimer's, in comparison with 42 matched bilingual controls.Naming tests have certain limitations. On the one hand, single word production does not require the speaker to retrieve and produce more than one lexical unit; no integration of the unit in a larger syntactic or discursive frame is required. On the other hand, the speaker is usually required to retrieve one very specific item without the support of an interlocutor. The most common context of language use is conversation. Spontaneous talk in conversation sets high demands on language processing by requiring extensive planning and production of sentences and longer coherent stretches of talk, such as narratives. On the other hand, word finding is facilitated by the fact that the lexical items occur in a natural context. Furthermore, the speaker can appeal to the interlocutor for help in word search sequences. Since word retrieval difficulties found on single word production tasks do not generally extend to connected speech in healthy aging subjects, there is no intuitive reason to expect them to do so in Alzheimer's patients.Combining different tools and methods of analysis makes it possible to produce a more comprehensive picture of the impact of the dementia on the speaker's languages. For example, a bilingual English-Norwegian man with the logopenic variant of Alzheimer's was tested across three different speech contexts, i.e., confrontation naming, semi-spontaneous narrative (picture description), and conversation, at 12 and again at 30 months post-diagnosis. Consistent with the man's premorbid use of and proficiency in the two languages, his performance in his L2 was lower than in his L1 for all three tests, but this difference diminished across the three speech contexts as the disease progressed. However, the difference was smaller in the narrative task, where his performance was already very low in both languages at the first measurement point.Some studies have had a longitudinal design, such as the case report of the bilingual English-Norwegian man with the logopenic variant of Alzheimer's (immediately above), in which the same people are followed over time; while others have had a cross-sectional design, which captures data from different groups of people (e.g., early- and mid-stage Alzheimer's patients vs age-matched healthy controls) at a specific point in time. Cross-sectional studies are less expensive and can be completed in a much shorter period of time, collecting data on multiple variables at the time of the data snapshot; but timing of the snapshot is not guaranteed to be representative, and findings can be flawed or skewed, especially if the sample size (number of patients and controls) is too small. Differences in study design may have led to what appeared to have been conflicting results from studies on language loss in bilinguals with Alzheimer's (see Ivanova et al below).Nanchen et al (2017) used a cross-sectional design to study the pattern of oral language impairment and its correlation with language immersion and proficiency in a study of 20 elderly bilinguals with mild to moderate Alzheimer's and 19 age-matched bilingual controls, all of whom acquired French as a second language and remained immersed in a French-speaking environment for decades. The use of age-matched controls was used to adjust for "normal" cognitive decline in the elderly associated with decreasing attentional abilities, potentially affecting language performance in general, and the ability to speak several languages in particular. Most of the study subjects had immigrated to a French-speaking environment as young adults. They often had francophone spouses and used French at their work place. L1 was the childhood language and school language. However, in adulthood, L2 was predominantly used both at work and for leisure. This everyday use plays a major role in language proficiency. An immigrant might only use his first language when traveling back to visit his family, in which case, the first language will not be used in the everyday life and the language of the host country might become more important. The results from this study suggested that L1 (the "mother/native" language) is not better preserved in Alzheimer's patients under these circumstances. The control group performed better for both L1 and L2 in comparison to the Alzheimer's group. Both groups experienced a parallel decline of L1 and L2 for both comprehension and production of language.Some studies have employed both longitudinal and cross-sectional designs. For example, Ivanova et al tested 12 Spanish-English bilinguals diagnosed with probable AD for naming accuracy on the Boston Naming Test once each year for three years (longitudinal analysis) and compared their performance to that of 14 matched, cognitively healthy, controls (cross-sectional analysis). Testing sessions were separated by 12.83 months on average. Eight patients and eleven controls were English-dominant, and four patients and three controls were Spanish-dominant. At each session, participants were instructed to name pictures first in their dominant and then in their non-dominant language. This testing order was adopted to match procedures as closely as possible to those of other Alzheimer’s Disease Research Centers in the US (in which bilinguals are tested only in the dominant language), and to minimize testing-order modulation of between-language interference effects which can affect the dominant language more than the non-dominant language. The main finding was that decline of the dominant and non-dominant languages followed different patterns cross-sectionally and longitudinally, thus replicating seemingly discrepant previous findings obtained with a single methodology. Longitudinal analyses of patients’ naming scores over time -- without comparison to controls -- showed the non-dominant language declining more steeply than the dominant language. By contrast, cross-sectional comparisons revealed greater differences between patients and controls for the dominant than for the non-dominant language, especially at the first testing session; thus, cross-sectional data differed most from longitudinal data at the first testing session. Taken together, these results suggest that both the non-dominant and the dominant languages are affected by Alzheimer's but might follow different decline trajectories over the course of the disease. The researchers hypothesized that the dominant language may be affected by Alzheimer's before the non-dominant language if decline begins with the most difficult -- and therefore most weakly represented -- words in the lexicon. Because bilinguals know more words in their dominant than in their non-dominant language, the most difficult and most weakly represented words for these bilinguals might belong to the dominant language and be unknown in the non-dominant language. Conversely, some words in the non-dominant language (e.g., high-frequency words) might be represented in a relatively robust way, for example because they are used more often, than the most difficult words in the dominant language. Thus, very weakly represented words in the dominant language decline earliest in Alzheimer's, words weakly represented in the dominant and non-dominant languages decline next (there would be more such words in the non-dominant language), and words robustly represented in either the dominant or non-dominant language decline last (there would be more such words in the dominant language). This hypothesis remains speculative, however, until additional studies with greater numbers of bilinguals, and at earlier stages of disease progression, are carried out. In the current study, some bilinguals were already in a moderate (and one was in a severe) stage of disease progression at Session 1; thus, the cross-sectional comparison occurred at a specific point during disease progression, and though longitudinal analyses illustrate naming deterioration from that point in the subsequent three years, important information from initial stages of the disease was not measured for most participants. Even though the study included both English- and Spanish-dominant bilinguals, the analyses demonstrated similar results and led to similar conclusions for English-dominant bilinguals alone. Still, given evidence that the effect of bilingualism on dementia might be influenced by variables such as education, country of origin, time spent in the country of immigration, and immigration status, future research is needed to study the possible effects of these variables on dual-language decline in Alzheimer's. It would also be useful to evaluate more complex forms of language ability at early stages of bilingual Alzheimer's.For additional information, see:How does the bilingual experience sculpt the brain?Costa A, Sebastián-Gallés N. How does the bilingual experience sculpt the brain?. Nature Reviews Neuroscience. 2014 May;15(5):336.Which Language Declines More? Longitudinal versus Cross-Sectional Decline of Picture Naming in Bilinguals with Alzheimer’s DiseaseIvanova I, Salmon DP, Gollan TH. Which language declines more? Longitudinal versus cross-sectional decline of picture naming in bilinguals with Alzheimer’s disease. Journal of the International Neuropsychological Society. 2014 May;20(5):534-46.Accessibility of the nondominant language in picture naming: A counterintuitive effect of dementia on bilingual language productionGollan TH, Salmon DP, Montoya RI, da Pena E. Accessibility of the nondominant language in picture naming: A counterintuitive effect of dementia on bilingual language production. Neuropsychologia. 2010 Apr 1;48(5):1356-66http://doc.rero.ch/record/305092/files/ann_slp.pdfNanchen G, Abutalebi J, Assal F, Manchon M, Démonet JF, Annoni JM. Second language performances in elderly bilinguals and individuals with dementia: The role of L2 immersion. Journal of Neurolinguistics. 2017 Aug 1;43:49-58. CitedDementia e NeuropsychologiaVeenstra WS, Huisman M, Miller N. Age of acquisition and naming performance in Frisian-Dutch bilingual speakers with dementia. Dement. Neuropsychol. 2014;8(3):249-259.

Millions of adults lack the level of education and training needed to get jobs that pay well, provide benefits, and offer opportunities for advancement. Research shows that people with postsecondary education earn more over their lifetimes and have lower-than-average unemployment rates.Increasingly, more states and localities are implementing career pathways programs to help adults navigate a path to jobs that pay well in their communities. Career pathways programs aim to improve the education and earnings of low-skilled adults by providing well-articulated training steps tailored to the local job market and accompanied by guidance and other supports. Career pathways programs focus on promising approaches to basic skills instruction and occupational training that lead to credentials for in-demand jobs. The programs also emphasize assessment, academic and non-academic supports that adults need to complete their programs, and connections to employers.The key components of a career pathways program include:Series of clearly defined and connected levels of education that build upon one other and lead to successively higher credentials and employment opportunities in growing occupations.Multiple entry and exit points.Comprehensive and intensive interventions to address the learning and life challenges facing adults.Strong connections to the local labor market and employer needs.Career pathways programs involve a range of industries and target populations. The pathway steps and associated credentials vary widely, too. Initial steps may include basic skills and training from a 6th grade level to high school. The next steps provide training geared to jobs requiring some training and education, but less than a four-year degree, such as occupational certificates and associate degrees. Higher levels incorporate bachelor’s degrees and advanced credentials. The programs are designed so students can enter and exit at multiple points along the pathway. Programs also tailor interventions and services to meet the needs of the targeted populations.Current Research and EvaluationThe U.S. Department of Health and Human Services’ Administration for Children and Families (ACF) has a number of ongoing evaluations to determine the effect of career pathway programs on participant educational attainment, employment, and earnings, especially for low-income individuals, including recipients of Temporary Assistance to Needy Families (TANF). Information on the ACF portfolio of career pathways projects, including the ones profiled here, can be found online.The Pathways for Advancing Careers and Education (PACE) EvaluationThe Pathways for Advancing Careers and Education (PACE) evaluation is the first-ever randomized trial of career pathways programs, featuring nine of the country’s innovative programs operated by community colleges, community-based organizations, and workforce agencies in 18 sites across 12 states (see map). The PACE impact study is testing whether these nine programs improve educational attainment, employment, and earnings among individuals who were assigned at random to a group that could access the program compared to a group that could not. Abt Associates, in partnership with MEF Associates, is conducting the study. Findings on the impact of the nine programs will be available starting in mid-2016.The nine programs in Pace are:Carreras en Salud, Instituto del Progreso Latino (Chicago, Ill.): Launched in 2005, Carreras en Salud (Careers in Health) is a career pathway program in nursing occupations for low-skilled and limited English proficient Latinos that leads participants from a Certified Nursing Assistant (CNA) degree to Pre-Licensed Practitioner Nurse (LPN) to LPN and ultimately to Registered Nurse (RN). Instituto designed Carreras en Salud to address both the academic and nonacademic needs of low-skilled Latinos. The training program provides a pre-college contextualized curriculum that moves students along an academic, career, and social ladder towards higher paying jobs.Workforce Training Academy Connect, Des Moines Area Community College (Des Moines, Iowa): DMACC’s Workforce Training Academy Connect (WTA Connect) program targets students with low skill levels who would not typically be eligible to enroll in vocational training certificate courses. The program aims to accelerate entry into vocational training by enabling students to pursue basic skills and occupational training simultaneously. The program packages vocational education in high-growth, high-demand sectors with basic skills remediation, psychosocial skills development, and advising, all at no cost to the participant. After completing the foundational components of the program, WTA Connect participants enroll in certificate courses in a variety of fields including health care and manufacturing.Patient Care Pathway Program, Madison College (Madison, Wis.): Madison College’s Patient Care Pathway Program (PCPP) provides accelerated entry into college-level programs in health for those with skill levels too low to meet entry requirements. PCPP offers two tracks depending on the student’s skill level: Patient Care Academy 1 (PCA 1) for students interested in a one-year health care diploma program or with skills too low to enter Patient Care Academy 2 (PCA 2); and, PCA 2, which allows students to meet all the prerequisite requirements in math, chemistry and communications for the two-year health degree programs in one semester. Both Patient Care Academies integrate developmental coursework with health program prerequisites and contextualize the developmental courses for the health field. All PCPP participants take classes as a cohort and had access to a dedicated advisor.Pathways to Healthcare Program, Pima Community College (Tucson, Ariz.): The Pathways to Healthcare Program trains low income Pima County residents, 18 years or older, for careers in high-demand healthcare fields. The program works closely with One Stop centers to recruit students, offering training in 16 different healthcare professions based on personal preference and test scores. The length of training can be as short as the five-week Nursing Assistant training, or up to two or three years for any of the associate degree programs (Clinical Research Coordinator, Health information Technology and Pharmacy Technology). Once enrolled in the Pathways program, students have access to a variety of supportive services including case management, remedial or developmental education if needed, a dedicated Pathways advisor, and a dedicated Pathways One-Stop Center case manager who works with them to find employment upon completion of training.Bridge to Employment in the Health Care Industry, San Diego Workforce Partnership (San Diego, Calif.): The Bridge to Employment in the Health Care Industry program assists participants in selecting a healthcare training program, provides advising and support services, and teaches job readiness skills. Participants receive individual training accounts (ITAs) to help pay for training; program navigators arrange for other financial supports, including funding for uniforms, certification fees, transportation, and child care.College Prep Academy, Valley Initiative for Development and Advancement (Lower Rio Grande Valley, Texas): Serving four counties in southern Texas, Valley Initiative for Development and Advancement (VIDA) funds training for people pursuing an occupational certificate or an Associate’s degree in allied health, manufacturing, information technology, business, education, and specialized trades. For those assessed with skills below college level, VIDA offers an accelerated bridge program, the College Prep Academy, to build reading and math skills. The program directly provides financial support to help cover needs like tuition gaps, childcare, transportation, licensing expenses, and financial emergencies. Weekly group or individual meetings with VIDA counselors aim to assist participants in addressing academic, personal, and professional issues.Integrated Basic Education and Skills Training Program, Washington State Community and Technical College System (Across Washington State): The Integrated Basic Education and Skills Training (I-BEST) program operates in all 34 of Washington’s community and technical colleges. I-BEST is a multi-occupation program that concurrently provides basic skills or ESL instruction and job training in a range of credit-based, occupational training programs along with counseling and other supports. I-BEST provides contextualized classroom instruction with two instructors in specified classes -- one instructor for basic skills and one for occupational content. Students also receive academic advising, supplementary academic and non-academic skills instruction, and tuition assistance if existing financial aid is not adequate. Three colleges are participating in the PACE evaluation:Bellingham Technical College (Bellingham, Wash.) : The I-BEST programs included in PACE are nursing assistant, automotive technology, welding, and electrical foundations. Everett Community College (Everett, Wash.): The I-BEST programs included in PACE are Nursing Assistant Certified (NAC), Sustainable Office Skills (SOS), and welding. Whatcom Community College (Bellingham, Wash.): One I-BEST program is included in PACE, clerical assistant.Health Careers for All, Workforce Development Council of Seattle-King County (Seattle, Wash.): The Health Careers for All program offers career exploration and planning, advising, and support services from navigators provided through a community-based organization. The program offers training at three levels—foundational, entry and advanced—providing multiple entry and exit points. Participants also receive job search assistance and continue to receive advising and support when they start working to assist with needs that arise and help determine future career options. Training is funded through ITAs, and WDC also directly purchases classes from colleges for cohorts of students.Year Up (PACE sites are Atlanta, Bay Area (San Francisco and San Jose), Boston, Chicago, National Capital Region (Greater Washington, D.C.), New York City, Providence, and Puget Sound (Seattle)): This intensive, one-year program provides high school graduates and GED recipients between the ages of 18-24 with a combination of hands-on skill development and corporate internship opportunities. The first six months of the program focuses on technical and professional skill-building, while the second six months focuses on applying these skills through corporate internships. An onsite social worker helps students access supports like housing assistance, affordable dental/medical services, and child care. The program provides financial support, including weekly performance-based stipends of up to $260 throughout the year. Students can also earn college credits for their participation (typically a maximum of 18-23 credits). After graduation, students continue to receive support and build their professional networks through Year Up’s Alumni Association.Additional PACE ResourcesOverview of PACEImproving the Economic Prospects of Low-Income Individuals through Career Pathways Programs:The Pathways for Advancing Careers and Education Evaluation: This policy brief from March 2014 presents a framework to describe the career pathways approach and the theory of change that guides the evaluation. It describes the nine programs in the PACE evaluation, and concludes with the study’s research questions and data sources.Pathways for Advancing Careers and Education Evaluation Design Report: This report from November 2014 documents the key research questions, structure, study components and data sources of the Pathways for Advancing Careers and Education (PACE) evaluation.Health Profession Opportunity Grants (HPOG) programAuthorized by the Affordable Care Act, the Health Profession Opportunity Grants (HPOG) program provides education, training, and supportive services to TANF recipients and other low-income individuals to help them get jobs in the healthcare field.In 2010, ACF awarded 32 five-year grants to government agencies, community-based organizations, post-secondary educational institutions, and tribal-affiliated organizations to conduct these activities in 23 states. HPOG aims to meet the dual policy goals of demonstrating new ways to increase the supply of healthcare workers while creating well-paid career opportunities for low-income, low-skilled adults. As of June 2015, nontribal grantees enrolled more than 37,000 people in 49 programs.ACF is funding multiple studies to examine the HPOG Program, including ones focused on program performance reporting, implementation and effects:HPOG Implementation, Systems, and Outcome (ISO) Evaluation Design and Performance Reporting. The HPOG ISO project has two parts. The first part developed an evaluation plan for HPOG and the second part built and maintains a management information system to track grantee progress for program management and accountability and to record participant data for use in the evaluation. This project produces the HPOG Annual Reports (see below).HPOG National Implementation Evaluation (NIE). The NIE includes an in-depth examination of HPOG grantee program design and implementation, a systems analysis of networks created by HPOG programs (e.g., among grantees, employers, and other partners), and a quantitative descriptive analysis of HPOG program outputs and outcomes. All 27 nontribal grantees are included in this analysis.HPOG Impact Study. The HPOG Impact study uses an experimental design to examine the effect of the HPOG program on participants’ educational and economic outcomes. This evaluation aims to identify which components of HPOG programs (e.g., types of support services, program structure, and training areas) contribute to participant success. The 20 grantees that are not part of the tribal evaluation, the University Partnership Research Grants, or the PACE evaluation are included in the HPOG Impact Study.Evaluation of Tribal HPOG. A separate evaluation has been designed for the five tribal grantees, given the unique contexts in which these programs operate. This evaluation focuses on implementation and outcomes and will offer lessons about diverse programmatic approaches to health professions training programs serving tribal populations.The HPOG Year 4 Annual Report shows that through the end of the fourth year, in September 2014, the majority of HPOG participants were single moms whose incomes fell below $20,000 at the start of the program. Almost half of participants had incomes below $10,000. More than 80 percent participated in a healthcare training course, with one-third enrolling in courses for nursing assistant, aide, orderly or patient care attendant. Other common courses include training for licensed and vocational nurse, registered nurse, medical records and health information technician, and medical assistant.The Year 4 Annual Report also reveals that many participants experienced positive outcomes (future reports from the HPOG Impact study will analyze the extent to which HPOG caused those outcomes). Sixty-five percent of those who began a course of training completed with many others still engaged in coursework. Nearly three-quarters (73 percent) of those who completed a course and exited the HPOG program were employed after leaving the program. More than 60 percent were employed in the healthcare field upon program exit. Nearly all participants (96 percent) also received some form of academic or personal support including tuition assistance, child care or transportation assistance, or employment placement support.HPOG Grantee LocationsOverview of HPOGHealth Profession Opportunity Grants: Year Four Annual Report (2013-2014): This report from June 2015 summarizes program operations and participant activity and outcomes from HPOG’s inception through the fourth year of grantee activities.Interim Outcome Study Report: National Implementation Evaluation of the Health Profession Opportunity Grants (HPOG) to Serve TANF Recipients and Other Low-Income Individuals and Interim Outcomes Summary Brief : This report from September 2014 (and summary brief from August 2015) provides interim results on the key outcomes of HPOG healthcare training completion and employment, as well as on participants’ pre-training activities and receipt of support services and employment assistance. This study includes 27 HPOG grantees and the report provides information about the first 12 months of HPOG participation for 8,634 individuals.Health Profession Opportunity Grants (HPOG) Impact Study Design Report: This report describes the research design of the HPOG Impact Study. The study is designed to answer questions about overall HPOG program effectiveness and explore how variations in program services affect program impacts, including identifying which elements of career pathways programs contribute most to advancing the labor market success of participants.Training TANF Recipients for Careers in Healthcare: The Experience of the Health Profession Opportunity Grants (HPOG) Program:As of April 2015, approximately 15% of HPOG participants were receiving TANF benefits at intake. This report explores two questions: How did HPOG participants receiving TANF benefits at intake differ from other low-income HPOG participants in characteristics, participation, and program outcomes? And why did TANF recipient participation levels vary across HPOG programs, and what are the implications for promising strategies to increase TANF recipient participation?