As we age, we become more liable to a number of conditions that can affect our communication. The same techniques that work with people who have communication impairments can sometimes help with older people with communication problems - and they're not complicated, not expensive, and always worth looking in to.

DEAL has written a book covering communication techniques to use with this group. It was specifically designed for nursing home residents, but the same principles apply.




Introduction

DEAL Communication Centre provides services to people with little or no speech.  In recent years our staff have seen many nursing home residents with communication impairments which were not being addressed.  Mr. C. was typical.

Mr. C was a sociable gentleman in his late seventies who had lost his speech after a stroke.  A double amputee, he lived in a nursing home.  The nursing home provided a good program of activities but did not have any speech therapy services and Mr. C could not afford private therapy.  The Activity Officer contacted DEAL to see if we could assist Mr. C.

Assessment showed that Mr. C understood what was said to him, and knew what he wanted to say back, but could not get the words out.  His spelling skills had been affected by the stroke, so he could not spell to replace his speech.  Nonetheless he could recognise written words, and sometimes these prompted his speech. 

Our goal was to enable Mr. C to converse successfully with his family, other residents and staff.  With the help of Mr. C’s wife and the nursing home staff we designed a communication album containing labelled photographs of Mr. C’s family, his house, the truck he used to drive (and a map of Australia so he could talk about where he drove), the bowling club he belonged to, and so on, as well as pages of drink and activity choices.  At the front of the book were empty pages, to hold photos or descriptions of current events. 

The book allowed Mr. C to initiate successful conversations and avoid many of the misunderstandings which had plagued him previously and had lead him to avoid social functions.  He spoke more, and the communication book helped people to understand what he was trying to say if his speech wasn’t clear or he couldn’t get the right word out.

Most nursing home residents referred to DEAL had lost the ability to speak due to strokes, though the group also included people with brain damage from other causes, and people with progressive conditions such as Parkinson's disease.  Without intervention aimed at improving speech or developing alternative means of communication, these people were at risk of being shut off for the rest of their lives, unable to ask for a drink, much less engage in conversation.

Towards the end of 1994 DEAL received funding from the Sidney Myer Fund for a pilot project to develop, implement and publicise a cost-effective strategy for meeting the communication needs of nursing home residents.  The goals of the project were to investigate the extent of unmet communication therapy needs in this population, to develop new strategies for service delivery, and to produce a report on the project and a resource kit of practical suggestions for helping nursing home residents with communication impairments.  In 1996 we produced a report called 'Unmet Needs - Enhancing Communication for Nursing Home Residents' and a resource kit called 'Everybody Needs It - Communication Resources for Nursing Home Residents'.  This booklet is a direct result of the pilot project, and contains some material from both the report and the resource kit.  It is written particularly for Directors of Nursing, Activity Officers and others concerned with the welfare of nursing home residents with severe communication impairments.
 
Acknowledgments

We would like to express our gratitude to

• the Sidney Myer Fund, for funding the initial project from which this booklet is derived
• the Healthy Seniors Program of the Office of Aged Care in the Commonwealth Department of Health and Family Services for funding the preparation and printing of this booklet, a copy of which will be provided to every federally funded nursing home in Australia

and

• the residents and staff of the nursing homes we visited, without whose co-operation no communication could have occurred.

1. Achieving Successful Communication

Communication occurs whenever a message is passed from one person to another.  The message may be spoken - 'Hello', written - 'Please shut the gate', or wordless - a smile of thanks, or a wave goodbye.

For communication to occur we all need

• Someone to communicate with
• Something to communicate about
• A means of communication
• A desire to communicate

1. Someone to communicate with
Communication requires more than one person.  For communication to succeed when speech is difficult or impossible and other strategies are used, a speech-impaired person needs a willing, patient communication partner.  Speech-impaired nursing home residents will only improve or retain their communication skills if staff have time to converse with them. 

2. Something to communicate about
Four broad purposes are served by communication.  These are:
i)   expression of needs and wants
ii)  provision of information, opinions as well as facts
iii)  maintenance of social closeness
iv)  social etiquette

i)  In nursing homes, most basic needs and wants  are met through the daily routine and staff usually become familiar with each resident's methods of indicating their everyday needs and wants.  Conveying needs and wants that are less easily anticipated is considerably harder.  For example, it is impossible for a non-speaking person to request new spectacles if they do not have an alternative means of communication and someone able and willing to spend the time needed for this message to be conveyed.

ii)  Information can often only be conveyed in the resident's own words, through speaking, writing or spelling. If speech is absent, and spelling is impossible, communication books with pictures and phrases which allow the resident to express opinions and relay basic information about themselves, their families and their interests should be used whenever possible.
Electronic typewriters, or other keyboards, are often recommended as communication aids for a number of reasons.  They are commonly used throughout society and so are more likely to be seen as 'normal' by residents.  They can be used with one finger of either hand, requiring less complex movement than handwriting.  And, most importantly, they allow those who can use them to communicate on any topic.

iii)  Social closeness  is very important for human beings.  Speech is our most usual means of interacting with each other, so impairment of speech severely effects our social closeness.  Likewise, loss of social closeness severely restricts recovery of communication skills.
The provision of communication aids such as conversation books and boards containing greetings and farewells, along with news and jokes, and the provision of enjoyable social opportunities reinforce each other.  For this reason the social stimulation provided by activity leaders in nursing homes is tremendously important for communication maintenance and recovery.  It is even more valuable when residents are enabled to take part in activities specifically designed to stimulate their communication skills.

iv)  Many non-speaking nursing home residents achieve social etiquette satisfactorily with facial expression, body language and gestures, but commonly used remarks such as 'Thank you' and 'Excuse me' should also be put on communication boards and programmed into speaking communication aids.

3. A Means of Communication
Multimodal communication should always be encouraged.  The mode(s) used on any occasion will depend on the person communicating and the type of information being conveyed.  The importance of facial expression and gesture should not be under-estimated.  It is useful to compile a list of non-speaking, severely-disabled residents' facial expressions and gestures and their meanings, to be kept close to their beds or in easily accessible books, so that everyone can respond to them consistently.
Individual communication boards and books containing selections of pictures and written words are invaluable for conveying basic information, needs and wants (see page X for suggestions on how to make communication books and boards).  All communication boards and books should be easily accessible, and travel around with their users rather than being kept in a cupboard.

Some residents will have comprehension difficulties due to deafness, receptive language loss and/or dementia, and will need questions to be put to them simply and patiently, accompanied by mime if necessary.  If questions requiring yes/no answers are used, the questions must be worded carefully to avoid confusion.

Every effort should be made to encourage speech, to redevelop language, and to provide a means for use of written language.  A typewriter or spelling board can be used for both communication itself and for language recovery activities.

4. A Desire to Communicate
There can be little desire to communicate if:
•    there is no-one available to communicate with
•    there is no-one prepared to try and understand
•    there has been no means of communication suggested to augment impaired speech
•    there seems to be nothing to communicate about.
Many residents in nursing homes are frustrated by their lack of speech.  With the provision of a variety of alternative means of communication, together with staff who make the effort to interact using these, your residents' desire to communicate and their success can be increased.
 
2. Definitions - Communication impairments

Articulation	production of speech sounds
Speech	production of sounds in combination
Language	use of words, gestures and expressions to make meaningful utterances
Communication	the process of exchanging information through verbal and non-verbal means.
Verbal communication	communication through words, either spoken, written or signed.
Non-verbal communication	communication that does not involve the use of words in any form - facial expressions, for example, gestures, or picture symbols
Severe Communication Impairment (SCI)	when someone is unable to communicate, or has great difficulty communicating because of physical or other difficulties
Augmentative Communication	anything that is used in conjunction with speech to supplement the message, eg. gestures, signing, alphabet board, etc.
Alternative Communication	something used instead of speech, eg. communication devices, communication books, spelling boards, sign language, etc.  The same strategies may be used to replace speech as are used to augment speech. Usually Augmentative and Alternative Communication are referred to together as AAC.
Expressive language skills	ability to express oneself using language; can be through speech, writing, spelling, sign language, communication aid, etc
Receptive language skills	ability to understand language, includes spoken and written word.
Dysarthria/anarthria	a disorder of the muscles required for speech production.  There may be weakness or paralysis of the muscles.  Speech can sound slurred and imprecise, or may be unintelligible.
Aphasia/dysphasia	an impairment of the ability to use and/or understand language.  It may comprise an expressive or receptive element or both.
Receptive dysphasia	difficulty understanding verbal and/or written language.
Expressive dysphasia	difficulty using language to express oneself, either with speech or in writing
Dyspraxia/apraxia	a disturbance of the ability to voluntarily produce skilled, co-ordinated movements, not due to muscle weakness.  Dyspraxia may effect any part of the body.  Oral or verbal dyspraxia involves the muscles of the mouth, and is a difficulty producing and sequencing speech and non-speech movements.  Dyspraxia can mask level of understanding, ie. make it seem as if the person has not understood an instruction.  Most standard tests will score a fail if the person doesn't do something. People may have more than one problem; they can be dysphasic and dysarthric, for example, or dyspraxic and aphasic, which obviously compounds their difficulties.

 
3. A Communicative Environment
Communication can be fostered or hindered by the environment.  A communicative environment is one in which everyone's communication is welcomed, and which allows everyone the chance to communicate to the best of their ability.  A communicative environment can only be maintained in a nursing home if:

• residents are addressed and treated with appropriate dignity
• communication is recognised as a vital human activity and there is a positive expectation that staff will communicate with residents
• staff have sufficient time to communicate with residents
• residents are positioned appropriately, both individually and in groups, to enable communication to occur
• staff know how each resident communicates and how to use any equipment needed
• appropriate communication aids are readily accessible to the residents who need them
• other individual aids - glasses, hearing aids, etc. - are properly maintained and put on for those residents who cannot do so themselves.
• there is something to talk about - choices to be made, activities to be planned, etc.
• activity officers are equipped to support and encourage aided and unaided communication
• lighting and noise levels allow written and spoken communication
• specialist help is sought for residents who are experiencing communication difficulties.

  Next chapter here.


Margaret Batt, Speech Pathologist
Cathy Maloney, Speech Pathologist
Rosemary Ryall, Physiotherapist
Ashok Sethi, Occupational Therapist
Rosemary Crossley, Augmentative Communication Specialist

DEAL Communication Centre,
Melbourne
1998