GETTING THE WORDS OUT

Enhancing Communication for Nursing Home Residents

DEAL Communication Centre, Melbourne: 1998

 

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.

and

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

 

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

1.1.  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. 

1.2. Something to communicate about
Four broad purposes are served by communication.  These are:

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.

1.3. 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 below 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.

1.4. 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, for example, facial expressions, gestures, picture symbols.
Severe Communication Impairment (SCI) = when someone is unable to 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.

 

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.
REMEMBER:

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?
7. 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, eg. "Do you want toast or cereal?"
8. 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?".
9. 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.
10. 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.
11. 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.
12. 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.
13. 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.  Try not to hurry, as this can provoke anxiety and make the person's communication problems worse.
14. 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.
15. 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.
16. 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.
17. 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.

Among 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.   

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. 


 

6. Communication boards and books

Communication boards and books enable people with a significant communication impairment to express themselves, by selecting items from a display for their listener to see.  The display can be in a variety of forms.  It may be a single laminated board, a folder, a photo album, etc.  There can be different displays for different situations or activities.  The material used must be strong enough to withstand frequent use, and may need to be water-resistant.  The decision about what type of format is most appropriate depends on a number of factors: pointing skills, visual skills, individual communication needs, potential partners, etc.

The items on the display may be photos, pictures, drawings, symbols, letters, words or sentences, or a combination of these.  Items can be grouped in various ways, and it should be easy to add new items or modify the layout - for example, there should be a section where the user's news can be quickly recorded and kept up to date.

The boards and books should allow the user to do more than just answer questions.  The person should be able to express feelings, communicate needs and wants, make choices, ask questions, make comments, state opinions, and start conversations.  The ability to initiate conversations, as well as respond to others, is an essential aspect of social interaction.  Assistance from an activity officer may be needed, perhaps to make the display, or to position it for the user, to assist them in learning to interact using the board or book, and to provide feedback about the user's communication.

Access to the display may be direct (eg. pointing to the desired item) or indirect (eg. partner reads out the items, and the user indicates when the desired item is said). Direct selection is nearly always faster than indirect selection.  Movements for direct selection do not have to be made independently.  The partner may need to steady the user's hand, or stabilise them physically in some other way.  Provide enough support for the person to reach the desired target successfully.  Gradually decrease the level of support as the person's ability and confidence increases.  Frequent opportunities to use the communication display meaningfully are essential if the person is to interact using the aid.

Letters as part of the display allow users to spell messages that are not available on their communication display.  If they are able to spell they have unrestricted communication, and can communicate anything they wish.  Letters can be arranged alphabetically, or in the QWERTY layout if the person is familiar with keyboards.

Communication books should be used for actual communication as often as possible, not for "testing" a person's skills.  They can be used meaningfully to:
•    tell someone news, eg. "I saw my grandchildren at the weekend."        
•    pass messages, eg. Telling another resident that they have a visitor.
•    make requests, eg. "Please put my T.V. on."
•    indicate choices, eg. respond to "Where would you like to go today?"
•    make comments, eg. "That show was boring" or "I am in pain"
•    ask questions, eg. "What's on today?"
 

7. Chat Books

People with communication problems often have difficulty expressing the most basic information about themselves.  A significant amount of our social conversations consists of talking about what we have been doing, where we've been, who we've seen recently, etc.  For people with limited or no speech, and no alternative means of communicating, responding to questions such as "What have you been up to?" can be impossible. 

A chat book or communication diary is one way for people with significant communication impairments to participate in conversations and share their 'news'.  This is simple to devise using a diary or a small photo album.  The book contains daily entries describing the person's activities and highlights for the day, as well as notes about special future events, such as outings or birthdays, etc.  This makes it possible for the person to pass on information, and interact with others in a socially meaningful way. 

Entries are written in the diary by as many people as possible during the day.  This gives conversation partners information about what the person did at different times of the day, and with different people.  Entries are written in the first person, that is, using ‘I’, so that it reads as if the non-speaking person wrote it.  For example, “I went out for a counter lunch with my niece, Sally, to the Imperial Hotel.  The place was very busy, so we had to wait for a long time to be served.  The meal was lovely.  I had pasta carbonara and a huge piece of chocolate cake for dessert.  After that the physiotherapist Jane was here.  We played some ball games.  It was fun but made my arm very tired.  Later I sat outside and read the paper.  Bill and I watched ‘The Footy Show’ before bed.”

It is important to check with the person that what you plan to write in the diary is okay with them.  Put in specific details of things like movies, places, and food to provide more information and reduce the number of questions needed to work out what the person did.

People should be encouraged to have their diaries in an easily accessible position in their room, and to show them to visitors and staff.  Responses to information in the diary should include comments, such as “I watched 'The Footy Show too.  I can't stand that Sam Newman - he insults everyone and thinks he's so wonderful. I enjoyed the bit with the St Kilda footballers. That was pretty funny.”, as well as questions.    

At the front of the book, it is useful to stick in photos of people and places which might be mentioned frequently, such as family members, friends, etc., making sure these are clearly labelled.  This provides more context for conversation partners. 

The main thing to remember is that the purpose of the book is to enable its owner to participate in regular conversations about what they have been doing.  The more information that is included, and the more frequently that the chat book is used, the better.  For residents who can't read, or can't read English, picture cues can be used for important entries, eg. a cake for a birthday.  If using a diary, staple a plastic envelope to the inside of the cover, to hold photos, postcards and such like, which the resident may like to show around.
 

8. Language Stimulation Activities

Here are some activities which stimulate communication skills. They can be used with individuals or as group activities. The activities range from very simple to quite complex.
•    Lotto games using pictures, letters or words
•    Matching games -  pictures to words, words to definitions, etc.
•    Crossword puzzles
•    Story recall - retelling stories that are well-known or have been read previously
•    Word finding exercises, eg. What do we wear on our heads?
•    Picture naming and picture descriptions
•    Discussions of selected topics, eg. jobs, foods, sports, royal family, entertainers
•    Task descriptions - eg. how do you make a cup of tea?
•    Giving news
•    Problem solving exercises - What would you do if?
•    Sharing personal experiences, eg. holidays/occupation/family events
•    Sale of the Century game
•    Multiple choice activities; answering questions from a selection of answers
•    What am I? games, solving riddles, etc.
•    Discussions of important historical events – the second World War, the coronation, the Melbourne Olympics, the Kennedy assassination
•    Planning menus - practice production of food names, etc.
•    Giving and following directions, eg. Simon Says (need to make sure this isn’t babyish)
•    Role plays, eg. pretending to order a meal or make a complaint at a shop, etc.
•    Non-verbal games - make a sad/worried/scared face
•    Chinese whispers
•    I spy
 

9. Resources for Enhancing the Communication of Nursing Home Residents

Resources for entertainment and language maintenance:
•    Local library - talking books, large print books, adult picture books (eg. travel books)
•    Braille and Talking Book Library - mails talking books free of charge
•    Radio for the Print-Handicapped
•    Channel 2 educational programmes
•    State Film Library - for borrowing educational and popular videos such as travelogues, train journeys, and nature programmes
•    Adult Migrant Educational Service libraries (for ethnic residents)
Orientation activities:
•    Large whiteboard in dayroom for day, date, weather, activities, etc.
•    Photos and reminiscences of earlier life - provided by family for individual residents - to help initiate conversation (see page  for chat book suggestions)
•    Pin-board above bed for family photos, etc.
Communication aids:
•    Cheaptalk 4 or other simple voice-output communication aid(s)
•    A keyboard - manual or electric portable typewriter, or notebook computer
•    Communication boards (laminated or in plastic envelopes) suitable for particular activities, eg. song and instrument choices for music session
•    Spelling boards (laminated or in plastic envelopes)
Materials for making communication books and boards:
•    Stick-on letters to improve visibility of letters on keyboard
•    Magna-doodle for writing on
•    Clear plastic eye-pointing board
•    A selection of laminated general-purpose communication boards
•    Small whiteboards (for offering written choices)
•    Whiteboard markers and wiper
•    White cardboard
•    Black and coloured markers, glue, scissors, etc.
•    Plastic envelopes from newsagent to cover communication displays, if lamination is not readily available
•    Cheap photo albums to make conversation books for individual residents.
 

10. Recovery After Stroke

Strokes often affect speech and/or the understanding of language.  The common speech problems following stroke are called aphasia or dysphasia, and involve difficulty in retrieving wanted words, and comprehension of language.

Recovery following a stroke occurs over a period of years, and varies according to the individual.  Of the people who survive a stroke, two out of three achieve some level of independence.  Family members may find it difficult that there is no established timetable for recovery.

The amount of recovery depends on several factors, including:
i)     The amount and extent of brain involvement. 
Problems will be most severe directly after a stroke.  There is a natural tendency towards improvement and healing.  However, an area of the brain that has been completely deprived of its blood supply dies and the cells cannot grow again.  The larger the area that is affected, the more likely it is that the person will have residual impairments.
ii)    The specific area(s) of the brain damage. 
Undamaged areas can take over the work of some damaged areas, and compensate for their loss.  This compensation is what therapy aims to stimulate.
iii)    The amount of stimulation
The amount of stimulation the person receives, and the timing of therapy influences their progress.  Although natural recovery does occur, therapy can complement this, and stimulate further recovery that would not have occurred naturally.  Residents with dysphasia should receive regular communication therapy and stimulation to encourage recovery and compensatory changes.  Therapy should be provided as early as possible for maximum benefit.
iv)    Motivation. 
The dysphasic person must want to regain his communication skills, and may have to work hard to do so.  Family members and friends play a crucial role in stimulating and maintaining the person's motivation.
v)    The person's level of awareness. 
Some people who have had a stoke have little insight into their dysphasia.  They may not have realise that they have a communication impairment, or insist that communication breakdowns are caused by other people's problems, not their own.   One of the goals of therapy with such people should be to increase their insight into their problems, so they can accept assistance. 

12. Structuring the Environment

Some of the difficulties in establishing communicative environments in nursing homes are associated with their geography.  Large rooms with many people sitting around are likely to be noisy, especially if they include a television set with volume turned up high to suit the hard of hearing. 
Maintaining a communicative environment in a nursing home is undoubtedly easier if the architecture allows residents to gather in small groups and meet with visitors with a degree of privacy.   

Nursing homes whose basic structure doesn't foster conversational groupings need to look at creative use of the spaces they have got.  Can the television be moved into a separate area or shielded from half the room?  Would a cafe style set-up, with small round tables, foster conversation?  Would the placement of comfortable chairs and sofas in the corners of public areas provide havens for conversational groups or residents and their visitors?

Communication is affected not only by architecture but also by furniture.  People who are using augmentative communication strategies, such as communication boards or books, need to be able to keep these with them and have a surface on which they can place them for use, especially if their hand function is impaired.  Wheelchairs and armchairs need pockets attached to the arm rests to enable belongings, including communication aids, to be kept close to hand.  Both arm chairs and wheelchairs can have fold-away tables attached.  Walking frames can have baskets with hinged lids which can act as tables.

Service needs

For residents to benefit from communication intervention two things are necessary:

Given the lack of familiarity with non-speech communication of many nursing home staff, therapy support is necessary not only for residents with communication impairments but for activity officers and nursing staff, to help them see residents without functional speech in terms of untapped potential rather than major limitations and to help frame programs, problem solve and provide resource materials.

Contact local hospitals, AAC centres, speech pathologist training centres, etc., for inservices. 

13. Electronic Communication Aids

Electronic communication aids provide an alternative means of expression for people with severe communication problems.  There are a number of devices available in Australia, ranging from typewriters to machines that speak a large number of messages.   

This list is inevitably somewhat outdated, but your AAC therapist should be able to advise you on newer devices.

Voice output devices (voice output devices are those that speak when the user presses a button).
Cheaptalk - the Cheaptalk is a basic voice output device available with either 4 or 8 keys.  The 4-key Cheaptalk is approximately 20 cm x 20 cm, is very lightweight and costs around $300.  The user selects from utterances which are recorded by a speaking person.  It has large keys and it is very simple to re-record new utterances, but may be perceived as childish by some residents.
Messagemate - the Messagemate is similar to the Cheaptalk, but has smaller keys. There are 3 versions available, with either 8, 20 or 40 keys.  It includes plastic sheets, which can have words or pictures on it, that are inserted above the keys.  Recording new messages is quick and easy.
Macaw - the Macaw is a voice output device with a much larger memory than the Cheaptalk or Messagemate.  This enables users to have a number of 'levels' programmed and stored.  Over 1000 utterances can be recorded on the Macaw, depending on the selected key size.  Messages can be quickly re-recorded.  Words and/or pictures are placed on top of the keys.  The Macaw has additional functions, such as the ability to link keys to create longer utterances, and can be set up to suit people with little or no vision.
Lightwriter - the Lightwriter is a text-to-speech communication aid.  This means that it says whatever is typed on it.  It also has memory functions which allow users to retrieve a number of pre-stored messages to speed up their communication.  
Print output devices:
Canon Communicator - the Canon Communicator is a small communication aid that prints whatever is typed onto a narrow strip of paper.  It is a very lightweight, portable device, which suits people with limited range of movement.  Sadly it is no longer commercially available but may be obtainable second-hand. 
Electric typewriters can also be used as communication aids, and may be familiar devices for many residents. 
It is possible for people without good hand function to use some of these devices, as the aids can be set up to be used with foot or head switches.
 

14.  Assessment, Therapy and/or Equipment Services

Some services offer advice and assessment regarding augmentative communication aids.  Training in the use of devices may also be provided.  A number of the following services are able to loan equipment for people to trial. 
ACT:
    
New South Wales:


Northern Territory:

Queensland:

South Australia:

Tasmania:

Victoria:

Western Australia:

 

15. Australian Group on Severe Communication Impairment (AGOSCI).

AGOSCI is a special interest group of communication aid users, therapists, teachers, and other people with an interest in severe communication impairment.  There is an AGOSCI representative for each state and territory in Australia, who should be able to provide information about assessment and training for communication aid use in their state.                       

16. Funding for Communication Devices

A few state governments have schemes which provide funding for the purchase of electronic communication devices.  For people who do not have access to such programmes, or are ineligible for some reason, charitable organisations sometimes help with the purchase of devices for individuals.  These include service clubs and charity groups such as the Variety Club and Rotary.    

ACT:
Funding for communication equipment in the ACT is usually done on a private basis.
New South Wales:
Funding for communication devices is available through the Programme of Aids for Disabled People (PADP). Restrictions, such as means testing, apply. 
Northern Territory:
The Territory Independence Mobility and Equipment Scheme may fund, fully or in part, purchase of communication devices; however, applicants must meet the scheme's eligibility criteria.  Tel: 
Queensland:
There is no government scheme in Queensland which funds communication devices for residents of nursing homes. Veteran's Affairs, Commonwealth Rehabilitation Services and the Worker's Compensation board may fund devices. 
South Australia:
The Disability Services Office and the Home and Community Care Program (HACC) provide equipment funding.  Tel: 
Tasmania:
Prescribed Aids for Disabled People (PADP) have supplied some communication aids to eligible clients.  Tel:
Victoria:
Electronic communication aids are funded through the Programme of Aids for Disabled People - Electronic Communication Devices Scheme (PADP - ECDS). Tel: 9254 5443.
Western Australia:
There is no government scheme in Western Australia which funds the purchase of devices for residents of nursing homes. 

17. Do’s and Don’ts for Receivers of Non-speech Communication

Do:

• be patient
  We can talk at 150 words per minute; many communication aid users cannot communicate at 150 words an hour.
• be confident
  Any nervousness or doubts on your part will certainly be transmitted to the aid user, usually with disastrous effects on their confidence.
• monitor your own communication
  Are you talking down to the aid user?  Do you raise your voice when you talk to someone who cannot speak?  Does your interaction consist largely of orders and prohibitions?
• use the right method
  Find out exactly how the user accesses the communication aid and how it should be positioned, and be consistent.  If possible, observe someone who is communicating fluently with the aid user and ask them to observe your early attempts.  Achieve success in small things before aiming for in-depth discussion.
• provide appropriate feedback
  In the early stages of communication it often helps the user if the receiver says each letter or symbol aloud as it is indicated, and repeats the utterance to date at the end of each word.  Further on, the user will probably prefer it if their partner does not say the utterance aloud until it is completed (and then only if it is not private).
• pay attention
  It is as important for the aid user to feel that you are interested as it is for you to feel the person you are talking to is listening.  If the aid user is inexperienced, monitor the output, and warn the user if you cannot understand so that corrections can be made before there is an irretrievable communication breakdown.
• offer word or sentence completions
  Remember, the purpose of aid use is communication, not a spelling test.  Most aid users will appreciate it if you complete the word wh the mean is obv.  But do be careful not to jump in too early and put words into the user’s mouth.
• look out for abbreviations, etc.
  Many aid users use contractions to speed communication, eg. RUOK.  Some use unconventional or phonetic spelling, eg. NE = any.  Interpretation is a lot easier if the user is encouraged to put spaces between words – at least then you know where one “word” finishes and the next starts.
• clarify meaning
  Many users produce telegraphic utterances (as we would in their place). A user whose communication system only has a limited vocabulary obviously has no choice but to make approximations.  In these cases it is necessary to play 20 questions to ascertain the user’s exact meaning.  Make it a practice to ask the user if you’ve got it right at the end of each utterance – if the aid does not produce written output it is very easy for the receiver to muddle a sequence of words or symbols.  Equally, the aid user is as prone to second thoughts and confusion as the rest of us, but has little chance to have a second go if we don’t check.
•  respond appropriately
  It is easy to get so involved in the process that one forgets that the user wants a response.  You may need to ensure tactfully that others around the user also respond.  It is very discouraging to spell “Hi, how are you?” with a great deal of effort only to be ignored.
• empower the aid user
  Arrange for the aid user to be able to make real choices(not just to ‘choose’ to have lunch when it is lunchtime anyway).  Act on the aid user’s requests and comments whenever possible, and explain and apologise if it is not possible.
• encourage aid use everywhere
  Our communication is not restricted to particular times and places.  Neither should an aid user’s be restricted.  Inconvenience is not a good reason to refuse communication.  If the situation is really difficult, ask if the communication is urgent.  If the communication is not urgent, fix another time for a chat and stick to it.  If the problem is practical, eg. an electronic communication aid cannot be used in water, try to find a practical solution, eg. a perspex communication board.
• encourage the expression of feelings
  Many aid users have used their aids only to make choices or answer basic questions, and need encouragement to enter into longer conversations and reveal more of themselves.
• respect confidentiality
  If an aid user says something clearly not designed for public consumption, resist the temptation to pass it on, no matter how interesting or amusing it is.  Adults (and children) have the right not to have everything they say reported to others.  If the user’s aid produces written output make sure this is disposed of carefully unless it was written to show someone else or you have the user’s permission to keep it.
• keep up your side of the conversation
  Volunteer your opinions.  Tell the aid user what you have been doing.  It is slow and tiring for the user to ask questions, and equally, it is abnormal (but unfortunately very common) for the aid user always to give information in response to your questions, but never receive any in return.
• recognise the effort and frustration involved
  Using a communication aid to give a message is far more laborious, and far more likely to be misunderstood, than giving the same message in speech.  Consequently, it is important that unnecessary or repetitive questions are avoided, e.g. asking someone what they had for lunch when you’ve just fed them.
• avoid testing
  Many aid users have very negative attitudes towards testing and may muck up and give rubbish answers.  After all, we are not required to establish our competence every time we open out mouths.  If we were, we wouldn’t talk very much.  The aid user who feels that every interaction is a test is likely to become resistant to the whole idea of communication.
• take the blame for failure
  If the communication attempt is unsuccessful, accept responsibility.  After all, you do not have the excuse of having a communication impairment!  Saying “I’m sorry. I’m not at my best today. Let’s have another go later.” helps the aid user to maintain their confidence.

Don’t:

• be negative!

18. Suggestions for Assisting a Person with Word Finding Problems

Some people have difficulty recalling or retrieving words from long-term memory in order to speak.  This word-finding difficulty results in word substitutions, imprecise use and over-use of empty words, repetitions and dysfluencies.
The following may help if a person is having difficulty finding a word.  These strategies may be used to facilitate and improve recall and retrieval from long-term memory.

• Use an associated word
  e.g. say “Bread and ....” to elicit ‘butter’.
• Use antonyms
  e.g. say “The opposite of night is ....”  to elicit ‘day’.
• Use synonyms
  e.g. say “Another word for lady is .....” to elicit ‘woman’
• Use the name of a category to elicit the name of a member of the group
  e.g. “It’s a fruit” or “You can use it to fix things”.
• Use serial cueing
  e.g. “Tuesday, Wednesday, ....” to elicit ‘Thursday’.
• Say the beginning sounds of the word,
  e.g. “m” to elicit ‘man’.
• Say the beginning syllable(s) of a word containing more than one syllable
  e.g. say “Hippo...” to elicit ‘hippopotamus’.
• Use sentence completion with a well-known sentence such as “We decorated the ......” to elicit target words such as ‘cake’, ‘tree’, ‘table’ or ‘room’.
• Provide multiple choices
  e.g. say “Is it a house, a tree or a chair?” to elicit ‘chair’.