Our guest chat host tonight on October 29, 2001, is Rosemary Lubinski, Ed.D.
Dr. Lubinski is a Professor in the Department of Communicative Disorders
& Sciences at the University of Buffalo. Her research and clinical
interests include communication disorders of the elderly,
communication in long-term care settings, aphasia, trauma, and stuttering. 
Dr. Lubinski has clinical experience in hospital, nursing home, and home health
care settings.  She has also supervised treatment for adult aphasic patients in the
University of Buffalo's Speech-Language & Hearing Clinic.  Dr. Lubinski is the author
of Dementia and Communication (1st Edition) and co-author of Professional Issues in
Speech-Language Pathology and Audiology (2nd Edition).  She will be presenting
a short course at the upcoming ASHA convention, SC22, Gerontology 101: Strategies
for Clinicians.

<Robin> We are very happy that Dr. Lubinski has joined us from the Univ. of Buffalo
<Robin> Dr. Rosemary Lubinski will talk tonight about communication and aging
<Rosemary Lubinski> I am suprised that my aging course does not attract more
    audiology students as the majority of their clients will be older adults.
<Robin> Dr. Lubinski, that is a surprise!
<Rosemary Lubinski> Yes, I agree.  But I think their focus is on technical coursework.
    We are now an Au.D. program in our second year, so perhaps they will have more time
    for electives.
<Stephanie> Hello Dr. Lubinski
<Anonymous5652> ...and I'm Linda S
<Rosemary Lubinski> Hello to everyone.  Thanks for joining us.
<Rosemary Lubinski> Please feel free to ask questions or make comments.
<Stephanie> I do clinic at a nursing home right now, and it is very challenging with
    some lower functioning clients. Dr. Lubinski, do you have some suggestions as to
    what activities are good for lower functioning clients?
<Rosemary Lubinski> I am not sure what you mean by lower functioning.  Do you
    mean seniors with dementia or severe aphasia?
<Stephanie> severe aphasia, such as global aphasia
<Stephanie> I also see another one with R-CVA with hypertonicity.
<Rosemary Lubinski> In general, your work with elders should be highly functional -
    focus on what the person is doing. Also focus on comprehension and expression of
    activities of daily living - eating, toileting, etc.
<Rosemary Lubinski> Also, focus on the intact social communication skills that may
    be present - ex. greetings, social situations, highly expected conversation topics.
<Rosemary Lubinski> Elders are a highly heterogeneous group.  Some will have
    hearing loss =- - about 50% of elders have hearing loss in the community and close to
    90% in nursing homes.  You must take that into consideration. Also be aware of vision
    changes - cataracts, macular degeneration, diabetic retinopathy, etc. 
<Stephanie> My supervisor suggested PACE, but I am not sure if it is a good idea to
    play PACE all the time.
<Rosemary Lubinski> I have found that using some closure type communication
    works well - where you leave off the final word and the client fills it in.
<Stephanie> How do you make it functional when you do closure type communication?
<Robin> for closure type activities, you mean a sentence or phrase completion task
    relating to ADLs ?
<Rosemary Lubinski> ADL- activities of daily living - toileting, dressing, ambulation,
    washing, talking.
<Rosemary Lubinski> I would make it very conversational - " This morning I had some
    toast for breakfast.  You ate some____.
<Rosemary Lubinski> This is in contrast with IADL's - instrumental activities of daily
    living - shopping, check writing, using transportation, etc.
<Stephanie> So you write out all the script before seeing the client? Should I plan for
    my script?
<Rosemary Lubinski> Re the script - perhaps at first you might want to give yourself a
    start - but you will find that you can become adept at this and take the lead from what
    the patient is doing or might want to talk about
<Adrienne FSU> I have found written choice to be better than a script
<Rosemary Lubinski> I also suggest that you bring in humor to your discussions with
    elderly clients - not laugh at but with.  Much of our therapy is too sterile.  Talk about
    something funny, bring in a joke or humor pix.
Rosemary Lubinski> Written choice is ok, too, but I like to be spontaneous and many
    elders have vision difficulties.  That's why it is important to know the sensory abilities
    of your pts.
<Adrienne FSU> true
<Adrienne FSU> My client has said he wants to understand humor more- any
    suggestions on how to work on that?
<Rosemary Lubinski> Re humor - if you are working with rt. hemi pts, this is difficult.  I
    find going to visual humor - more concrete- works better than verbal humor. Some rt.
    hemi don't even know when something is funny.
<Stephanie> My rt. hemisphere pt does not use much facial expressions, too.
<Rosemary Lubinski> You are right.  This is one of the cardinal characteristics of rt.
    hemi pts.  Working with a mirror can be helpful.  I have also used pix with variety of
    facial expressions and had the pt both identify and match the pix.  You might try talking
    about the contexts where various facial expressions are used.
<Rosemary Lubinski> I also try to mention something amusing that happened to me -
    or incongruous- and ask the person his or her opinion. That is often a good way to get
    the session focused on more nonliteral topics.
<Stephanie> One of my written goals is to have my client answer simple questions.
    Could you give some example of what questions I could use for simple and functional
<Rosemary Lubinski> I would make a list of the types of things that family or staff need
    to talk to the patient about - ask them.  That will make it more functional than only what
    you think the pt might need to express or understand. 
<Rosemary Lubinski> You might make a chart of these and categorize
    them by function and expression vs. reception.
<Stephanie> My client cannot move his hands, too. This makes therapy even more
    challenging for me.
<Adrienne FSU> Stephanie- can your pt connect the facial expression with the
    associated emotion?
<Adrienne FSU> eg. does he understand a frown means sad?
<Stephanie> I am not sure. I have not tried that yet.
<Rosemary Lubinski> You might try getting several pix of the same emotion and have the
    patient put like emotions together into a catetory.  I would not start with too many
    emotions at one time and stick to those that are meaningful and contrasting,
    ex. happy vs. sad
<Stephanie> sorry, could you explain what pix mean? English is  not my first language.
<Rosemary Lubinski> pix = pictures
<Stephanie> thank you.
<Anonymous5652> I would probably pull out a representative picture of the emotion,
    say, frustration, that the pt is expressing at the time
<Rosemary Lubinski> Are any of you working with patients with dementia?
<Adrienne FSU> not my regular client, but on my Diagnostic rotation, yes
<Stephanie> I don't, but one of my client's roommate's has dementia. She often couldn't
    find her room.
<Rosemary Lubinski> Going back to the communication changes with aging- not only
    hearing and vision, but there may be some changes in auditory comprehension and
    word finding even in normal eldery.
<Rosemary Lubinski> These are usually not evident until very old age. Some people
    will comment on their word finding or tip of the tongue difficulties - this is often benign
    aging diffficulty.
<Stephanie> My client who is rt hemi also has anomia.
<Rosemary Lubinski> Anomia can be present in rt hemi patients - usually the biggest
    problems are in comprehension of nonliteral communication - proverbs, metaphors,
    incongruities, inferences, etc.
<Stephanie> My rt hemi client also stops answering questions sometimes. He acts like I
    am not there occasionally.
<Adrienne FSU> what sort of treatment would you do for those more analytical skills?
<Rosemary Lubinski> I am particularly interested in the communication environment of
    elders - the influence of the physical and social environment on communication skills
    and opportunities of elders especially in nursing homes.
<Stephanie> It seems to me that residents in a nursing home do not need to do much
    to take care of themselves.
<Rosemary Lubinski> Yes, you are right - learned helplessness sets in as people
    withdraw and are given fewer opportunities to do things for themselves and control
    their environment through communication.
<Rosemary Lubinski> Going back to the rt. hemi pt.  - again, you need to concretize
    your therapy as much as possible - the here and now, the observable, what is around
    the person. These clients do not do well with abstract information.
<Stephanie> Yes, my supervisor did told me that I need to make everythign concrete.
<Adrienne FSU> so they will never get to where they can understand abstract things?
<Rosemary Lubinski> It is not a question of never understanding abstract information,
    but of what degree of abstract information.  This is also true of TBI patients.
<Stephanie> Dr. Lubinski, do you have any suggestions of how to communicate with
    the elderly effectively besides talking slowly? Especially being an ESL speaker, I have
    an accent.
<Stephanie> and talk loudly.
<Rosemary Lubinski> Suggestions - do not talk overly slow - this is degrading and
    childlike.  Speak naturally, a little slower, do not shout or raise your voice unnaturally,
    pause appropriately, speak in somewhat shorter sentences that are well formed, alert the
    listener about the topic to come, face the person, be sure lighting is sufficient - elders
    need 3 times more light than you and I do, do not change topics abruptly. Complete one
    idea at a time.
<Stephanie> So, to give instructions. Is it better to say "What is this" rather than saying"
    Could you tell me what this is?"
<Rosemary Lubinski> I would try to avoid too much confrontation naming - try to make
    your therapy more natural - it can flow from a good conversation that you manipulate
<Stephanie> so we should maintain one topic each session? I think that coming up
    with an appropriate topic and talk for 20-30 min is challenging.
<Stephanie> especially for the lower functioning clients
<Anonymous8745> Hello. I do not work with the elderly, but I am very interested in this
<Robin> glad you could join us 8745
<Rosemary Lubinski> I think elders are sometimes taken back, perhaps even
    insulted, when therapy is too teaching like - dogmatic - what is this, name this.  etc.
    Try to make a conversation with your client that allows him or her to express ideas,
    wants, knowedge, etc.  Use a memory book or pictures that reflect on the person's history and family.
<Rosemary Lubinski> Capitalize on what the person did for a living, special interests
    or abilities.  I also talk about the decades when the individual was younger.
<Rosemary Lubinski> These are good memory joggers and many elders will be able
    to retrieve words and apply their abilities to these topics.
<Stephanie> I understand this. My client used to be a truck driver, but he appeared to
    be very confused at times. He could not recognize his family pictures either.
<Rosemary Lubinski> You need to be sure that you know the family members names
    before you use pictures or memory books that have family members in them.
<Rosemary Lubinski> Otherwise, you must rely on the person's word finding skills to
    inform you.  You need to plant or manipulate the conversation carefully.
<Rosemary Lubinski> Your goal is to bring out or enhance the existing skills to the
    highest ability possible.
<Rosemary Lubinski> You might try bringing in some of your family pix and showing them
    and naming the persons.  Personally, I think memories about the person are more
    significant than forcing the person to say a name,. 
<Stephanie> But is it degrading to ask "Is XX your son's name?"
<Stephanie> I see. Could you give an example of what I may say using his family member's name?
<Rosemary Lubinski> For example, tell a short story about your father in a pix and then
    look at a pix of the client's.  Encourage him to tell you something about the pix - does
    not have to be the name. Some memory or experience- too much focus on word finding will make the
    person more self conscious of his difficulties.  Focus on a goal to get meaning across
    rather than specific words.
<Stephanie> Sounds like great ideas. Thank you so much.
<Adrienne FSU> My pt has the opposite problem- all he talks about is himself!  In
    group therapy, we are trying to get him to ask other people questions...
<Adrienne FSU> he doesn't have the turn-taking and pragmatic skills for a functional
<Rosemary Lubinski> Adrienne - are you sure that this is a suitable client for therapy?
    What are his auditory comprehension skills like? 
<Rosemary Lubinski> Are there any spontaneous comments?
<Adrienne FSU> he has great auditory comprehension
<Adrienne FSU> he is high functioning, left CVA
<Adrienne FSU> he was previously a professor and discovered that neurons
<Adrienne FSU> he tells me he has always been "pretentious" and now he realizes he
    can't talk to the "less intelligent" people at his assisted living facility
<Rosemary Lubinski> Before I leave, if any of you would like to contact me at the U of
    Buffalo, please feel free to do so through email - cdsrosie@acsu.buffalo.edu
<Rosemary Lubinski> What other questions or comments do you folks have?
<Robin> Any more questions regarding clients or therapy ideas?
<Stephanie> Thank you very much, Dr. Lubinsky, that was very helpful.
<Amelia> thank you, I enjoyed the discussion.
<Rosemary Lubinski> I hope that each of you will avail yourselves of some practicum
    experience with elders - home care, nursing home or hospitals - it is really vip.
<Adrienne FSU> Thanks for coming on tonight!
<Rosemary Lubinski> It has been fun.  Good luck to you all in your professional careers.
<Stephanie> Thank you.
<Robin> Thank you Dr. Lubinski
<Robin> We appreciate you taking the time to join us tonight!
<Rosemary Lubinski> Robin - this has been great - hope you ask me again
<Robin> We will definitely ask you to join us again!
<Robin> Goodnight!