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.




Last chapter here.
 
4. Interacting With Residents with Aphasia
Many people suffer communication impairment following a stroke.  The most common communication impairment is called aphasia (or dysphasia).  People with aphasia have difficulty expressing themselves and/or understanding speech.  There are many ways in which you can help an aphasic person cope with his difficulties and use his remaining language skills.  Because a person cannot speak and be understood, or seems unable to listen and understand, this does not mean he is unable to communicate.

1. The person is essentially the same person he was before his stroke.  The inability to communicate effectively is a sign of the dysphasic condition; it is not a sign of general mental incompetency or childishness.
2. Regardless of the severity of his language loss, the resident must be treated as a mature, intelligent adult.  Include him in decision making as much as possible.
3. Do not talk about the resident and his problems in front of him, even if you think he cannot understand.  Even someone with comprehension difficulties can pick up the tone of your voice, body language, etc.  If you must say something in front of him, let him know that you realise it is unpleasant to be discussed. 
4. Do not treat the dysphasic person as if he is deaf, and shout at him.  This does not help him to understand and may actually make it more difficult for him.
5. Speak and move in a relaxed manner.  Face the resident as you speak. Say his name first to establish his attention.  If the person has difficulty understanding, use short simple sentences and clear language.  Slow down your speech so that the person has time to take in what you are saying.  Use gestures and facial expression to help communicate your message.
6. If the person has difficulty speaking, phrase questions so that he can answer yes/no.  Yes/no questions should have one, not two parts.
           Example:   
           Would you like tea?
           NOT
           Would you like tea or coffee?
   Some people with dysphasia may indicate 'no' when they mean 'yes' and vice versa.  If this occurs provide other ways to respond, for example, use multiple choice questions. If possible, show the resident the objects as you ask the questions, e.g. "Do you want toast or cereal?"
7. Be alert to the resident's gestures, and eye signals, so that you can gauge his responses.  When you do interpret body language, check with him, eg. "Did you mean no?".
8. Sometimes a person with dysphasia will "get stuck" on a particular sound, word, or phrase, and repeat it many times (perseveration).  This can be a result of fatigue, a lack of coordination, or anxiety about communication.  The more that this is repeated the more habitual it becomes, and therefore harder to stop.  Gently stop the person, and acknowledge that you are aware that they are trying to say something else.  Ask them to relax, take some deep breaths and try again in a few minutes.  Do not encourage the perseverative response in any way, as this leads to increased frustration for the person.
9. Don't speak for the person unless it is absolutely necessary.  Anticipating what the person wants to say and saying it for him is natural, but sets back his language progress, and can be very frustrating.  Encourage him to say it himself, or to use alternative communication forms, such as pointing, even if it is slow.  Be patient, give the person time to speak, and try not to interrupt his speech efforts.
10. Never assume that the person is not trying.  He is not lazy or playing games with you.  He is trying to communicate under very difficult conditions.  Sometimes he will be unable to say something that he said a few minutes before.
11. Don't push an aphasic resident when he is tired (and he will tire much more easily than he did before).  Communication attempts will be most successful when he is rested and alert.  Pushing him will only create frustration and perhaps depression.
12. Make sure that you have the person's full attention and that they have yours.  Try not to do other tasks at the same time as talking with him.  Also try not to hurry, as this can provoke anxiety and make the person's communication problems worse.
13. The unintentional use of swearing and emotional phrases is sometimes part of the condition.  Try not to respond to swear words, and acknowledge that you know that it is not what the person meant to say.
14. If the person has slurred speech (dysarthria) gently remind him to take a breath before speaking, say each syllable clearly, and slow down his speech.  If he drools, gently remind him to close his mouth, purse his lips together, and swallow frequently.
15. If you can't work out what a resident is trying to say, encourage him to use gesture, eg. "Show me what you want", or communication aids.  Ask questions which narrow down the subject, eg. "Is it about your family?", or "Are you asking me to do something for you?"  There will be times when you won't be able to work out what the person is trying to tell you.  If this happens, apologise and suggest trying again later.
16. Allow the person to do all that he can for himself.  This will help him to re-establish himself and maintain his self-esteem and confidence.  Confidence is particularly important.  A resident who is not confident that staff will welcome his communication attempts and help him to get his meaning across is unlikely to try to communicate.

 
5. Evaluating the Communication Skills of Residents
Yes/No responses - as part of getting to know a person, we often ask questions that require a yes/no answer, such as "Did you have a comfortable trip?", "Do you like your room?", or "Are you warm enough?".  A yes/no response that is known and understood by all staff is essential for people with severe communication problems.  At the time of admission, family members should be asked if they have established specific yes/no responses. If so, the responses should be documented and passed on to all staff.

If not, when you are talking with the new resident, note if he indicates 'yes' or 'no' in any way, for example, nodding or shaking his head, saying 'mmm', putting his thumb up or down, etc.  If you are unsure whether he is responding to your questions, tell him so, and ask him to show you how he indicates 'yes' and 'no'.  Record any clear responses for use by other staff.     

Speech Comprehension - you can often get a general idea of someone's level of comprehension during ordinary conversations.  Does the person seem to follow the conversation and respond to your comments and questions appropriately?  Does he understand what you say without you needing to frequently repeat or rephrase your messages? 

If the person has little or no speech, you need to look for other indications that he has understood your speech.

• Does the person follow instructions when no visual cues are given, for example, "Can you give me the book?" or "Lift up your arm"?
• Does the person laugh at jokes?
• Does the person look at objects as you name them, such as photographs, people, furniture, or personal belongings?
• Does the person show signs of confusion or difficulty understanding?

It is very important, but sometimes hard, to distinguish between difficulties related to memory problems, or hearing or physical impairments, from those directly related to a comprehension deficit.  The presenting characteristics can be similar, but are due to very different reasons.  Someone with a hearing impairment will have trouble understanding speech if your mouth is covered, or when there is a lot of background noise.  A person with memory problems may nor remember how he got to the nursing home, or what he had for lunch, even though he can understand the question.  Someone with a motor dyspraxia may not be able to perform an action when asked, despite knowing exactly what it is he has been asked to do.  Obviously management strategies will differ according to the nature of the problem.

If a person is capable of understanding most of your conversational speech, then it is likely that he has sufficient comprehension skills to manage without special strategies being required.    

Expressive Language Skills - again, a person's participation in conversation can provide you with a basic idea of his expressive language skills.
Things to notice are:

• Can the resident speak in full sentences?
• Does he produce sentences of varying length?
• Can he comment on things, ask and answer questions?
• Does he use a variety of words?
• Can the person speak fluently, without excessive hesitation or repetition?
• Does the person leave words or sounds out?
• Does the person comment that they know what they want to say, but can't think of the words?
• Do you often need to ask him to repeat himself, and if so, why?  Is it because you aren't getting enough information, or because there are words that are unclear or don't make sense?
• Is there any indication that he is having trouble finding the words that he wants? For example, does he gesture to show you what he means, or act like the word is on the tip of his tongue, but he can't quite retrieve it? 

Articulation/Quality of Speech - some people will have difficulty with the actual production of speech sounds.  This will be evident during conversations with them, and may fluctuate according to fatigue, medication, etc.

• Does the person's speech sound normal?
• Does his speech sound slurred?  If so, are certain parts of the sentence or particular sounds effected?
• Is the person's speech ever unintelligible?  If so, is it unintelligible often or just occasionally?
• Are there any signs of muscle weakness in the face?  For example, is there drooling from either side of the mouth, or does the right side of the face seem slightly lower than the left?
• Does the resident complain of changes in his speech?
• Is his voice loud and strong, or is it soft or harsh?

If the resident does not speak spontaneously, you can try some automatic speech tasks, such as counting to ten, or reciting the days of the week, etc.  Tell him that you want to hear what his voice is like, so that he doesn't find the exercise insulting.  Other automatic speech tasks include saying the alphabet, the months of the year or well known rhymes.   

Following up your evaluation – If a resident appears not to be able to hear, check whether his file contains a recent audiology assessment.  If so, follow through on its recommendations. If not, ask the resident’s doctor to examine his ears, and make an audiology referral if appropriate.

If a resident has articulation or fluency problems, check whether his file contains a recent speech assessment.  If so, follow through on its recommendations.  If not, arrange for a speech assessment.

If a resident has very little or no speech, and no alternative communication strategy, check whether his file contains an AAC (augmentative and alternative communication) assessment.  If not, arrange for a referral to a specialist AAC centre or therapist (see list on page x).   

Recording outcomes – It is very important that information about the communication strategies and needs of residents with severe communication impairments is readily available to all staff.

If there are a number of such residents, it is useful to maintain a chart at the nursing station which lists specific difficulties (eg. ‘deaf in right ear’), communication strategies (eg. thumb up = yes/thumb down = no) and communication aids (eg. uses communication board which hangs on the back of his wheelchair).  Such a chart can also include information on necessary equipment such as hearing aids and glasses which the resident needs in order to communicate but may not be able to ask for. 


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