BMH Medical Journal

BMH Med. J. 2020; 7(Suppl): Early Online. Geriatrics & Gerontology Initiative: International Workshop on Care of the Elderly

Communication is an important matter of concern in elderly. This is due to the fact that communication breakdown can escalate into emergencies at many instances. Physiological changes and increased incidence of neurologic conditions with aging leads to communication disorders. It is estimated that 45 to 50% of the geriatric population has communication disorder (Muche & McCarty, 2019). Disorder of communication can occur due to the impairment in one or more of the following domains such as speech mechanism, language, cognition and hearing. Also, the extend of impairment vary from individual to individual. Therefore, the population in need of rehabilitation forms a heterogeneous group with a few common clinical observations.

Some of the signs that indicate the need for speech, language and/or hearing intervention in elderly include:

• Trouble with hearing in noisy situation
• Asking frequently for repetition
• Listening at unusually loud volumes
• Difficulty in seeking attention to express daily needs
• Reduced response or request
• Avoiding verbal communication
• Word finding difficulty and frequent word transposition
• Difficulty in managing personal matters
• Decreased awareness of personal safety and dangerous situations
• Trouble swallowing or choking

The rehabilitation professionals in the field of speech and hearing help to retrain and regain the ability to communicate and swallow. The intervention of communication disorders are extended to the individual with the disorder and the communication partner. Rehabilitation emphasis is on the application of various evidence based techniques and aids to restore and/or retain the communicative skills. However, Specific strategies may not be successful in all patients. In such conditions, environmental modifications and maximizing the intact communication modality is recommended.

The most common communication disorders and the rehabilitation strategies recommended for geriatric population are:

Hearing Loss

According to the statistics of National Institute of Health (NIH) one in three people over the age of 60 experience hearing problem. This figure increases to 50% over 80 years of age. Hearing loss in elderly is typically of the sensorineural type. High incidence is for presbycusis followed by ototoxicity and middle ear dysfunction. Increased threshold of sensitivity and reduction in speech understanding at comfortable levels are the key symptom. Poor auditory threshold interfere with the speech perception and affect the comprehension of spoken language. Also, inadequate auditory feedback during speech reduces the articulatory efficiency. American Academy of Audiology pointed out that untreated hearing loss is linked to depression and social isolation. Thus it is crucial to watch out for signs of hearing difficulties.

Rehabilitation

The most common way to tackle hearing loss which cannot be treated by medical management is by the use of auditory prosthesis. The auditory prosthesis includes hearing aids, Bone Anchored Hearing Aid (BAHA), cochlear Implant (CI), middle ear implant, and Auditory Brainstem Implant (ABI). Of all types of auditory prosthesis, hearing aids and cochlear implants are used for individuals with cochlear pathology. Mosnier et al. (2015) reported improved cognitive function post auditory rehabilitation post cochlear implantation in elderly.

Recommendation for cochlear implantation in elderly can be done only if the following candidacy criteria are met:

• Etiology of the hearing loss: a strong consideration in the decision to implant.
• Individuals with medical contraindications such as cochlear ossification, an absent cochlea, chronic middle-ear infection, or retrocochlear hearing loss cannot be considered.
• Presence of postlingual severe to profound sensorineural hearing loss.
• A score of 50% or less on open-set sentence recognition 65 dB SPL in the ear to be implanted when optimally aided.
• A score of 60% or less on open-set sentence recognition when both ears are aided.
• Motivated, emotionally stable patient, with realistic expectations, who is willing to attend for the required number of assessment, mapping, and training sessions.

In addition, considering the risk of surgery and other individual factors cochlear implantation in elderly are very rare. Thus, predominantly hearing aids are used. Earlier research indicated that use and benefit of hearing aid is less for elderly compared to young adults (Jerger & Fleming, 1985). However, recent literature has found no relationship between age and use of hearing aids (Meister et al., 2015).

The contra indications that may stop or postpone hearing aid fitting include: hearing loss of sudden onset, rapidly progressing hearing loss, otalgia in either ear, tinnitus of sudden recent onset or unilateral tinnitus, unilateral or markedly asymmetrical hearing loss of unknown origin, vertigo, headaches, conductive hearing loss, atresia or other deformity of the external ear and other chronic medical conditions.

Challenges faced during fitting: Lack of awareness regarding the hearing loss and readiness for hearing aids, social stigma, manual dexterity that compromises the abilities to manipulate hearing aid controls, insert hearing aid batteries and position the hearing aids in the ears, sensory difficulties beyond hearing loss (touch and vision)and low cognitive function.

Role of audiologist:

1. Explain the nature of hearing loss, its consequences, and treatment options (including both devices and procedures).
2. Help the patient acknowledge the presence of hearing loss.
3. Help the patient overcome obstacles that discourage to accept any form of rehabilitation.
4. Instruct and encourage the patient to use of hearing aids, or other assistive listening devices.
5. Setting realistic expectations. Educate the patient that hearing through hearing aid is different from natural hearing.
6. Help the patient acquire additional communication skills in the form of listening and communication strategies.
7. Provide perceptual training in understanding speech. This training can comprise analytic and synthetic speech training, in auditory, visual, or auditory-visual presentation modes.

Hearing aid selection and fitting: Hearing loss in elderly is mostly symmetric in nature. Hence, bilateral fitting is advised for individuals with significant hearing loss. Advantages of bilateral fitting are improved speech intelligibility, good sound quality, improved localization, avoid late onset auditory deprivation and suppression of tinnitus. Unilateral fitting is sometimes preferred due to cost, binaural interference, self image, and other miscellaneous factors such as wind noise interference, occlusion and maintenance issue.

• Hearing aid style:

Different hearing aid styles include spectacle, body level, behind the ear, receiver in the canal, in the ear, in the canal, completely in the canal and invisibly in the canal. Of all the types spectacle and body level hearing aids are rarely used. The table given below indicates the advantage of each model on different criteria.

In elderly the most preferred hearing aid style is BTE and RIC considering the loss, configuration of loss and dexterity.
• Fitting formula: Choose appropriate fitting formula based on patient preference on trail and following evidence based practice. NAL-NL1 and NAL-NL2 is considered for typically sloping hearing loss pattern.
• Coupling devices: BTE hearing aids and RIC hearing aids are coupled to the ear canal by using moulds and domes respectively. The type of mould or dome to be chosen will depend upon the acoustic need.

Adjusting to new experiences with sound and hearing aids: Most of the inexperienced users of hearing aid reject the fitting within few days of use. This can be avoided by providing a gradual build-up to the sound perception through hearing aid. Utilize the provision of acclimatization in digital hearing aids to gradually improve and accept the hearing via hearing aid. Also, advice to follow listening in step form:

1. Listening to one other person at home while you can see his or her face.
2. Listening to a TV or radio at home.
3. Walking around inside your home, trying to recognize any sounds you can hear.
4. Listening to one other person at home while you are not looking at their face.
5. Listening to music.
6. Listening to your own voice while you read aloud from a newspaper or book.
7. Conversing with two or three people in a quiet place.
8. Walking around outside, trying to recognize any sounds you can hear.
9. Shopping or talking to another person in a noisy place.
10. Conversing with two or three people in a noisy place.
11. Conversing in a large gathering or at a noisy restaurant.
12. Special situation if any

Following a specified listening program: Listening situations are different for each individual. As the patient start using hearing aid they will hear background sounds that they have not heard for some years. Counsel to learn hearing strategies to ignore sounds that don’t carry meaning and attend, label sounds that carry meaning. Different hearing strategies include:

• Observing the talker and surroundings: Lip-reading, non-verbal signals, filling in gaps.
• Manipulating social interaction: Clear speaking, gaining the listener’s attention, knowing the topic, repair strategies, giving feedback, disclosing the hearing loss
• Manipulating the environment: Lighting, positioning, minimizing noise, minimizing reverberation and adjusting the source

Auditory perceptual training: Auditory perceptual training is categorized into two general types: Analytic or perceptual speech training and synthetic or active listening training. Analytic training is aimed at increasing patient's correct perception of the individual sounds of speech, using predominantly bottom-up auditory processes. In contrast, Synthetic training aims to alter patient's behavior when communicating, increase their confidence when engaging in communication, and strengthen their use of predominantly top-down processes when making use of incomplete information.

Clear speech: Use of clear speech by speaker is a significant strategy to individuals with hearing loss. It utilizes exaggerated articulation at slow rate of speech. 17 to 20% increase in speech intelligibility was noted when speakers were asked to change from use of conversational speech to clear speech. (Helfer, 1998).

Computer-Based Auditory Training at Home: There are several computer-based auditory training programs:

● Listening and Communication Enhancement (LACE) 1765 comprises tasks involving speech perception in babble and against competing talkers, time-compressed speech, and closure skills (deducing missing words in sentences from context).
● Seeing and Hearing Speech 1603 focuses on auditory-visual speech-reading training
● Conversation Made Easy 1806 focuses on speech reading training and hearing strategies.
● Read My Quips 1046 focuses on speech-reading training in noise using humorous sayings to maintain motivation.

Assistive Listening Devices: ALD's are devices that improves signal to noise ratio by acting as an intermediate channel between the speaker and the hearing aid user. Though ALDs provide a huge improvement in speech perception, the successful usage is limited. This is due to technology aversion, cosmetic appearance, manipulation difficulties, physical discomfort, and poor knowledge about using.

ALDs that alert the user to environmental events are also available recently. Alerting ALDs comprise a sensor of some type linked to an output that can be easily detected by the hearing impaired person. The most common sensors/detectors or triggers are: telephone ring sensor, baby cry sensor, smoke detector, alarm clock and a doorbell.

Adult Language Disorders

Adult language disorder includes dysphasia/aphasia caused mainly due to stroke. According to the National Stroke Association, one in four people who have a stroke will develop aphasia. Though there are several different categories of aphasia, no two individual will have completely similar symptom. The condition involves varying impairment in domains such as auditory comprehension, spoken language, naming, repetition, reading and writing.The outcome of aphasia rehabilitation depends on various factors such as aphasia severity, lesion site and size, age gender and other co-morbid conditions. (Payabvash et al., 2010).

Rehabilitation

• Constraint Induced Aphasia Therapy (CIAT): Promotes the use of verbal communication rather than the non-verbal ways like gestures. Follow the principle of massed practice. As the patient’s function performance improves the difficulty of required tasks is gradually enhanced according to patients’ functional performance. Zhang et al., in 2017 indicated that massed practice to be a useful component of CIT.
• Visual Speech Perception: Make use of visual stimulation thereby associating certain words with pictures for cognitive retraining. Fridriksson et al. (2012) indicated improved response in individuals with non fluent aphasia especially in Broca’s aphasia.
• Promoting Aphasic’s communicative Effectiveness (PACE): It was developed by Davis and Wilcox (1981). Conversational exchange is trained. The clinician and the patient exchange the roles of speaker and listener. It emphasizes on communication rather than grammatically correct forms of expression.
• Response Elaboration Training: Technique used to increase the length and information content of the utterance in individuals with non fluent aphasia. Rather than semantic and syntactic complexity of utterance, effective communication with expanded sentence production is targeted.
• Tactile/kinesthetic treatment for alexia and agraphia: Intervention at alphabet level. Tactile treatment involves tracing the outline of letters on patients’ skin and asking them to name the letter. Kinesthetic treatment involves having patients write or trace letters with a finger before naming the letters. A combination of tactile and kinesthetic training involves instructing patients to trace letters onto their own skin.
• Object to script matching: In the initial step, the clinician will tag each of the object with respective script followed by naming. Later the patient will be instructed to tag the objects with respective script.
• Multiple Oral Re-reading: Used in individual with improved word reading. The strategy targets text reading. The patient will be asked to read the same text aloud over and over. The main hypothesis of such a treatment is that familiarisation with the text, namely the context of the sentences (syntax and semantics) will promote top-down processing rather than bottom-up LBL-reading. This increased reliance on top-down processing will lead to a generalization of untrained texts.

Motor speech disorders

The class of speech disorder includes dysarthria and apraxia. The conditions are caused due to neurological impairment that limit the ability to plan, program, control, co-cordinate and execute speech production. Dysarthria is a result of motor execution deficit affecting the muscles of speech mechanism. Example: Lesion of UMN or LMN, Parkinson's disease. On the other hand, apraxia occurs due to inappropriate motor planning characterized by no weakness or paresis of muscles of speech mechanism. Mainly due to fronto-parietal damage or in association with Broca's aphasia.

Rehabilitation

Rehabilitation of dysarthria include strategies to improve the functions of speech sub system such as respiration, phonation. resonation, articulation and prosody. It is done by strengthening the muscles responsible for speech production, changing the rate of speech, improving the respiratory support, increasing phonatory control and precision of articulation. Apraxia rehabilitation includes methods to improve corordination and sequencing. It also incorporates sensory strategies to improve awareness of articulatory movements and contacts during speech production.

The different intervention strategies can be classified as:

• Speaker-oriented treatments are patient oriented. The strategies make use of instructions and practice to help the patient to compensate the speech and language problems independently.

• Oromotor exercises: Utilises the principle of muscle retraining or compensation strategies. Focus on exercises to prevent muscle deterioration while gaining strength is practiced.
• Prompts for Restructuring Oral Muscular Phonetic Targets (Champelik, 1984): Make use of tactile cues to improve kinesthetic and proprioceptive feedback to facilitate speech production. The clinician act as an external programmer providing systemic cues for spatial and temporal aspects of speech production. PROMPT is paired with auditory and visual stimulation. It is an evidence based technique in management of apraxia.
• Melodic intonation therapy (MIT. Helm-Estabrook, Nicholas & Morgan, 1989): Making melodic intonations to make utterance fluent which the patient can’t express by speaking. It doesn’t target on sound accuracy. Repetition is the core of MIT. It uses high probability utterances with semantic value to the patient. It begins with hand tapping rhythm to hum in unison and fading clinician’s model. As the basic is acquired linguistic material is added.
• Lee Silverman Voice Treatment: A promising program for persons with Parkinson’s disease. It focuses on the voice and modifies laryngeal pathophysiology through exercise designed to increase loudness and decrease breathiness. It emphasis on high effort, multiple repetitions and increasing sensory awareness of loudness and effort.

• Augmentative and Alternative Communication is a system of communication that is utilised to supplement or replace speech. It aims to help people with more advanced speech problems to communicate with residual ability. Based on the technology used communication using AAC is classified as low mid and high. Low Tec AAC make use of sign language, gestures, communication board, communication book, tactile aids, Picture Exchange Communication System etc. Mid Tec AAC uses battery operated devices such as Bigmack, Talk two, Super talker and high Tec AAC uses advanced technology using gadgets and applications. Example: computerized voice output communication aids (VOCAs), AVAZ and other communication apps.
• Listener-oriented strategies involve educating and empowering the listener to better understand the person. For example, family members are taught about active listening to help them understand the speaker.

Dementia

The disorder results in chronic progressive deterioration in intellect, this affects functions of communication and personality. It is characterized by generalized slowing, decline in verbal working memory, deficits in inhibitory processes, attention and/or sensory and perceptual processes. Example: Alzheimer's disease, Frontotemporal dementia, Lewy body dementia etc.

Rehabilitation

• Spaced retrieval training: It is an evidence-based memory technique that uses procedural memory to help people recall information over progressively longer intervals of time. Patients are trained for recognition of newly taught stimuli and perform newly taught procedures. Two ways of establishing include: (a) Cue behaviour association – trained to perform specified actions in response to verbal or non verbal cues. (b) Object name association – trained to recognize faces or to select objects from an array in response to their spoken names.
• Errorless learning: This is an instructional method applied to individuals with compromised memory and executive functions. Error reduction is targeted at various levels of learning. The graded tasks include strategies of immediate error correction, modelling the task steps and reducing the frequency of guess.
• External aids: A compensatory strategy used in individual with impaired prospective memory. It is regarded as easier to use, more accurate, and more dependable, than mental strategies. Example: Electronic organiser with built in alarms, Digital voice recorder, entering appointments in a diary or on a calendar, writing a memo, using pocket sized checklist, taking photographs of various incidents, programmable watch, PDA (personal digital assistant).

Tips for better communication with elderly

• Communication will be gradual. Allow extra time for the individual to understand and respond.
• Avoid distractions: Reduce background noise
• Sit face to face.
• Use nonverbal cues. For example, maintain eye contact and smile.
• Speak slowly, clearly and loudly.
• Use short, simple words and sentences.
• Refer to people by their names than pronoun.
• Talk about one thing at a time. Individual may not be able to engage in the mental juggling involved in maintaining a conversation with multiple threads.
• Don’t quibble. It’s okay to let delusions and misstatements go.
• Learn to listen. Good communication depends on good listening.
• Look for hints from eye gaze and gestures. Take a guess
• Simplify and write down your instructions. Writing is a more permanent form of communication than speaking. It provides the opportunity for the patient to later review in a less stressful environment.
• Ask to repeat the instructions. Since repetition leads to greater recall. Combine written and oral instructions.
• Use charts, models and pictures. Visual aids will help patients better understand.
• Frequently summarize the most important points.
• Begin the conversation with casual topics or topic of interest. Talk about familiar topics such as family members and special interests of the person.
• Give them choices to ease decision-making.
• Give opportunity to ask questions and express self.

The primary intention of speech and hearing rehabilitation is to promote communication. Hence, it follows a holistic approach to reduce the impact of deficit on function, activity limitation and participation restriction. Thereby, an attempt is made to improve the quality of life of elderly.

References

1. Dillon, H. (2012). Hearing Aids. 2nd ed. Turramurra: Boomerang Press/Thieme.

2. Duffy JR (2005). Motor speech disorders: substrates, differential diagnosis, and management.2nd ed. St. Louis, Mo. Elsevier Mosby.

3. Ilias P & Patrick C. (2017). Aphasia and Related Neurogenic Communication Disorders. 2nd ed.

Speech And Hearing Rehabilitation In Geriatrics