Winter 2010

Communication Partners
By Deborah Crabbs MacDonald, MS, CCC-SLP
Aging Well
Vol. 3 No. 1 P. 14

For an older adult whose communication skills are compromised by disease or trauma, a communication partner offers a vital connection to verbal expression.

Humans are social creatures. While that’s not news, it’s important not to overlook that fact while caring for an older adult who has an acquired communication disorder. Most of us are fortunate enough to have multiple means of expression and reception available to us—speaking and listening, reading, writing, gestures, and facial expressions. We communicate daily via e-mail, telephone, and various continually growing means of transmitting information. In each case, communication doesn’t occur without at least one sender and one receiver.

Becoming a patient due to a new medical diagnosis presents numerous challenges that vary according to the condition and its severity. All elders deserve to receive clearly presented information, particularly in light of its critical use in decision making. Despite varying differences in learning style and capacity to understand all of the pertinent details, older adults have the right to ask questions to understand options and likely outcomes. Emotions that are triggered by the experience of serious illness often interfere with an individual’s ability to comprehend and evaluate information. When the disease or event involves the impairment of an elder’s ability to communicate, there is further interference with treatment and recovery.

In the event that normal communication is interrupted by illness, disease, or trauma, treatment ideally involves at least one familiar communication partner in addition to the patient. A communication partner is just what the term implies: one who is on the opposite end of the sender-receiver connection. In a best case scenario, this partnership begins at the entry point to the healthcare system, whether it’s in a physician’s office, hospital emergency department, or an individual’s home.

The ideal communication partner knows the individual well. Familiarity with the elder’s personality, educational background, health history, language background (primary language/additional language), and cultural background is valuable when it comes to assessing the level of functioning following the onset of a communication disorder. Information about an elder’s communication style—preference for interaction with individuals or groups, degree of daily use of reading and writing, sense of humor, and sophistication of vocabulary and language usage—are valuable.

Partnering for Progress
An older adult who experiences aphasia (impairment of language understanding and usage) as a result of an insult to the brain may face the greatest communication challenges compared with other types of communication impairments. The difficulty with communication may simply involve poor word retrieval or range to an almost total inability to speak recognizable words. Individuals with aphasia may experience extreme difficulty comprehending verbal or written language. To an uneducated observer, they may seem to speak a foreign language. Older adults with aphasia often believe that because of their difficulty putting words together to express thoughts, others perceive that they lack intelligence.

Initially, it’s essential to provide aphasic elders with a means for expressing basic needs such as being hungry or the need to use the bathroom. Some individuals develop this independently through speech or gestures. Others require a speaker to present options to which he or she can respond “yes” or “no.” Those with severe verbalization impairments may require a picture board that allows them to point at images to indicate their needs.

As an older adult’s medical condition stabilizes or changes, communication requires modifications. The course of treatment often involves transfer from an acute care setting to a rehabilitation setting and/or a skilled nursing facility. In addition to the experience of tremendous loss that accompanies the illness, the adjustment to each new setting, with its different culture, environment, and staff, can be unsettling.

Facing such challenges as though surrounded by speakers of a foreign language, older adults benefit from the assistance of a communication partner who can educate staff about the individual’s cultural background and how it affects personal attitudes toward healthcare. The partner can take time to explain a procedure—a few times, if necessary—so the individual feels more comfortable about it. Because the partner is familiar with the elder’s life prior to the onset of aphasia, the partner can explain to staff a longtime disdain for oatmeal, accounting for the individual’s limited breakfast intake. A skillful partner may think of stories or activities that could effect a positive mood change. Although they may seem obvious, or even trivial, for an elder whose sending and receiving circuits are blocked, they become essential considerations.

Involving a partner who is a spouse, friend, or family member in communication training offers several advantages. Treatment objectives that target the successful exchange of information can be measured as a clinician observes the elder and the partner communicating with one another, providing assessment of communication in its most functional sense. For example, an older adult is shown a photograph of a fictional Thanksgiving dinner, unseen by the partner. He or she is asked to describe it for the partner using any means necessary (speaking, gesturing, drawing, etc). As the partner guesses what is depicted, the individual responds, adjusting as necessary until the message has been successfully transmitted.

Since the clinician (speech-language pathologist) has the advantage of knowing what is pictured, he or she is able to coach the patient on what information should be communicated to the partner. The clinician may also coach the partner regarding the most helpful strategies to elicit useful information from the patient. Such strategies can be carried over into various settings outside the treatment clinic. In addition to its usefulness in preparation for real situations, this scenario can be enjoyable for everyone involved.

Creative Strategies for Improving Speech
Communication disorders that accompany progressive diseases affecting the nervous system, such as Parkinson’s disease or amyotrophic lateral sclerosis (ALS), differ from aphasia. These disorders involve the speech production system rather than language production and usage. Dysarthria is the broad descriptor of symptoms that involve changes in any or all of the following aspects of speech: voice, respiration, resonance, prosody (rhythm and tonality), and articulation. The speech of an older adult with dysarthria may be slower or faster than normal, the volume may be low, there may be a more nasalized quality, pronunciation may be poor, or the delivery may be monotone. Elders with dysarthria often experience difficulty coordinating breathing with speech. Typically several of these characteristics are involved in an individual’s speech pattern. Unfortunately, most of these symptoms worsen as the disease progresses. In some cases, an augmentative communication support becomes necessary as speaking becomes a decreasingly successful means of expressing thoughts, wishes, and needs.

The communication partner’s role—as an important element in the feedback loop—becomes key early in this progression. The partner becomes the older adult’s functional reminder to monitor his or her own speech production. In response to training provided by a speech-language pathologist, the communicators can develop a system for signaling to the dysarthric speaker that revision is necessary. It could be as simple as a request to repeat, which triggers the implementation of strategies developed to improve speech intelligibility. When partners are included in the treatment, they practice conversation with the training clinician’s supervision. Partners become familiar with the specific modifications an individual has been trained to use to improve speech intelligibility and can provide cues to the elder to utilize them. With such a system in place, partners can avoid getting caught in an endless loop of “What did you say?” followed by a repetition of the same unintelligible message.

Case in Point
Here’s an example illustrating the ideal use of partners. Phyllis, a delightful woman in her late 70s, has been diagnosed with ALS. Her speech has been deteriorating gradually for about one year following her first visit to the outpatient speech therapy clinic. With her breathing obviously affected, Phyllis requires oxygen at all times. She takes frequent labored breaths while speaking and sometimes fails to clearly mark the spaces between her words. She frequently abbreviates multisyllables. Sometimes she speeds her speaking rate in an attempt to squeeze the desired words into one breath. Her volume is sometimes low. In the quiet setting afforded by the speech clinic, it’s easy to understand nearly everything Phyllis says. Her home setting with its usual ambient noise is larger and more open. Conversation often involves more than one person in addition to Phyllis. She usually tires by day’s end and her speech intelligibility suffers.

Phyllis lives with family members and frequently spends time with other family and friends. At least one family member accompanies her to each treatment session. She first learns to control her breathing for optimal support of speech. When she masters such control to the level of accurate self-critique, she addresses speech pacing and articulation. She practices reading sentences that she and the clinician can see to her family member. The partner then parrots back what he or she has understood. Phyllis either says “You got it!” or practices specifically trained revision strategies to sharpen the message. As she becomes increasingly successful, the practice moves to longer sentences, summarizing paragraphs, and eventually conversation. The speech pathologist observes each phase, coaching both Phyllis and the partner of the day. She reminds Phyllis about the finer points of breath control and reminds the partner about skillful feedback. She also suggests to Phyllis and her partner that because it becomes too taxing to converse later in the day, evenings are not the best time to receive visitors. It’s also important to consider how a visitor who wears a hearing aid should be positioned relative to Phyllis for optimal comprehension.

As the treatment course nears its end, the clinician shows Phyllis and her relatives several devices that may be worth considering as Phyllis’ disease progresses. It’s likely that speech will become considerably more difficult and intelligibility will suffer. She may eventually want to use a keyboard with electronic speech output capabilities to augment her own verbal expression. As a former office assistant, Phyllis has excellent typing skills. Her cousin listens to the spoken sentences Phyllis has typed into the device and comprehends easily.

Phyllis enjoys communicating with several family members who have been trained to cue her appropriately when her speech becomes difficult to understand. They’ve learned to gently remind Phyllis what to do when she loses track of her breathing or syllable marking. And they’ll lend their support when the time comes for more treatment or to include a keyboard or other assistive device in her communication repertoire.

Providing Tools for Effective Speech
Inclusion of a partner to provide supervised communication practice as part of rehabilitative training is not limited by diagnosis or the setting in which an older adult is treated. By incorporating this type of instruction in speech and language therapy, a speech-language pathologist provides tools for enhancing typical communication experiences that older adults may encounter outside the clinic. In residential or outpatient settings, partners can attend treatment sessions to learn specifics related to the individual who is affected. Home care easily lends itself to partner involvement when there is a partner who shares the residence.

Absence of a support person in the life of an older adult with a communication disorder is especially challenging. The nature of communication requires at least two participants. One criterion for treatment planning is developing functional skills. While a person typically reads a newspaper or writes a check alone, a listener is required to validate a speaker’s message. The elder without family or friends who are available to participate in treatment lacks a vital piece of the communication rehabilitation experience. Volunteers could potentially be involved to provide conversational practice for such a person. A volunteer who is trained by a speech-language pathologist is then available not only as a companion but also to provide opportunity for the impaired communicator to hone skills.
Losing the ability to communicate is a devastating experience. Impairments of speech, language, reading, writing, or comprehension substantially impact a person’s connection to others. Conversational practice is an important element of rehabilitation for an older adult with an acquired communication disorder. While a speech-language pathologist can provide practice by conversing with a patient, training other partners affords additional advantages. This aspect of training nurtures the true connection, the ability to express opinions, hopes, and fears in addition to basic needs. A trained clinician can observe conversation and provide feedback for both partners to increase their communication success. This allows smoother transitions from clinic to real world and provides the tools to support patients as well as their loved ones.

— Deborah Crabbs MacDonald, MS, CCC-SLP, is a speech-language pathologist at Berkshire Medical Center in Pittsfield, Mass.

Aids for Aphasia
The Aphasia Institute in Toronto “is an internationally recognized Canadian resource that works in partnership with communities and others to break down language barriers, build communication ramps, and rebuild lives for those affected by aphasia,” according to the organization’s Web site. The institute trains volunteers to act as communication partners for people with aphasia. Training is also available for speech-language pathologists and other healthcare professionals.

In addition to working directly with older adults with aphasia and their families, the center advocates for opportunities for elders to live their lives as fully as possible. The institute publishes printed resources for professionals who work with patients with aphasia. There are also publications available that are specifically designed for older adults whose language has been affected by aphasia. These guidebooks use pictographs to promote easy comprehension for older adults who may experience reading impairment. The Aphasia Institute’s Web site—www.aphasia.ca—includes descriptions of the various training programs offered, lists of publications available, related resources, and contact information.