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.

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.
•    Cross word 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 (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 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 is an important factor in recovery.  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 is also important.  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:
i) interested, informed staff and
ii) therapy and equipment resources. 

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.   

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.
 

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