Speech Therapy and Aging: Brain Plasticity and Cueing Hierarchies

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Given our knowledge of the plasticity of the brain, are we as clinicians or caregivers, able to help to develop new links with a behavioral model, by using gradated cueing hierarchies?  Could this low-tech and pharmaceutical-free form of treatment  have neurologically based implications for rehabilitation and adaptation in communicatively challenging settings?

Perhaps more testing with fMRI scans may be necessary to really prove the theory. Therapy approaches using cueing models have been well documented in the literature in speech therapy treatment for aphasia.  However, the way we use clinician originated cues can help create new links and expedite a broad area of cognitive and linguistic improvement, or maintain the functional status quo, unless we analyze the kinds of cues we are using and the amount of independence we are carefully eliciting from the client.

By looking at each task and cue needed on a continuum from simple to complex, concrete to abstract, you can construct a grid of where on the continuum the client functions and how you can provide a cue or help them provide their own cues for success.

The idea that the damaged axons and dendrites in the brain are looking for connections and stay active when the brain is activated, prompted me to want to create a cueing continuum (see http://carmichaellab.neurology.ucla.edu/integrated-view-neural-repair-after-stroke.) On the theory that the client can develop new pathways , if we always fill in the missing word or provide the first phoneme, then the client will never have to learn where to get it, via their own written word, for example.  But how do we get from writing the word for the client to having the client write the word in the air and say it? It all depends on the residual abilities, but the concept can be applied to everyone.

We have a 60 year old gentleman with TBI who is learning how to semantically cue himself to find a word. Initially, he had severe speech and cognitive impairments. Now, in conversation, he often uses circumlocution to get his point across. However, sometimes specific words are warranted, and this is difficult for him. He can sometimes spell the word aloud even though he cannot speak it. We had him do this several times with great success. Our next task was to remind him that he could do this to help himself.  Later we only asked him what he would like to do.  We are helping him build those dendritic links ( and learn to use a skill) by carefully reducing the amount of clinician prompting or cueing during the sessions and writing down the strategies for him to practice at home. Although there are many approaches to cueing, none of them seem to describe cueing in a continuum from most invasive to most independent. Many clinicians describe the cues as semantic or phonemic.  I found that there were nuances in cueing that I had learned over the years to allow the client to gradually become independent. When I had difficulty transmitting these ideas to my students, I created a loose continuum to mark where our clients fell given specific objectives, and how we could get their neurons to get closer together behaviorally if not actually by breaking the cues down.

Along with the goals we establish for our clients, no matter their abilities, we must always be evaluating their behavior and trying new materials and varied activities to facilitate language.

As we converse with others, we derive cues from the environment and from the people with whom we are speaking (that is part of the reason why conversation amongst the adult neurologically language-impaired looks better than when we test them by looking for specific words and longer utterances).

Our goal with cueing is to develop self-cues and elicit more language. A self-cue can be as basic as a gesture or a drawing, but if the client is doing it and communicating to me what he did for the weekend, then he has been successful. Often when the stress is lower or the focus is away from speaking, the words and incidental phrases flow more freely. The best reward is to see the expression on our client’s face when he says a few words effortlessly because he was engaged in the activity. But this is not we what we are trying to do. We are trying to give him real tools for those times he cannot utter a word.

When the client leaves the therapy room, we want him or her to be able to use their own skills, rather than rely on others. Since they may not be able to develop their own means of self-cueing, we include self-cue skill development as part of the therapy plan.  The client may or may not have the ability to provide his or her own cues, yet. But throughout the therapy and rehabilitation process, we work toward the skills of self-cuing no matter the level, such as writing, gesturing, drawing pictures, and talking about the item or activity with words that are available.

The Cueing Hierarchy Continuum is by no means linear, but will generally go from simple and most dependent to complex and independent. They follow the behavioral branches that may be used in clinic therapy logs. They are separated on my behavior grid in 3 categories: Clinician Assisted Cues, Clinician prompting (or reminding the client to use a strategy) and Self Correcting. This approach requires that the client learn about his strengths and how to implement them to improve what we would consider weaknesses. By identifying which cues are more dependent, we can be cognizant of allowing the client to work at a documented realistic level achieve the objective.

It is well documented that there is enough plasticity in almost any brain to stimulate, heal and renew brain function after a stroke or TBI. For cognitive loss during normal aging, the dementias and the progressive dementias, there is less clear documentation for which approaches are the most effective and pragmatic for our clients. However, similar principles can be used to establish functional objectives along with the family and caregivers.

How to develop skills? How to develop strategies for short and long-term functional success?  Sometimes, we spend the therapy session working on comprehension, word finding, writing and reading using a variety of materials.  But, if we don’t address what they are learning outside the therapy room, which they may visit one or two times a week, how will compensatory skills, adaptive skills and  new connections be utilized?   That will be the topic for next month’s post.

Betsy C. Schreiber, MMS, CCC-SLP, received a BA in Psychology and MMS Master of Medical Science in Speech Pathology from Emory University in Atlanta, Georgia. Her CCC was earned during the 3 years she worked at Hitchcock Rehabilitation Center in Aiken, South Carolina where she had the opportunity to learn about NDT and Sensory Integration with the original, Jane Ayres, working with LD and CP children and neurologically impaired adults. She is currently a clinical supervisor at Ladge Speech and Hearing Clinic at LIU/Post on Long Island, and a partner at Hope 4 Speech Associates, P.C. She has also served as an ASHA Mentor and hopes to participate in ASHA’s  Political Action Committee in the coming year. She is an affiliate of ASHA Special Interest Groups 2, Neurophysiology and Neurogenic Speech and Language Disorders, and 18, Telepractice.

Speech Therapy and Aging: Implications for Our Approach to Communication Disorders

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This post is the beginning of a monthly series by Betty Schreiber, M.M.S. CCC-SLP, on Aging, Communication, Cognition, and Speech Therapy.

Thank you for allowing me to be a new blogger on ASHASphere. I currently supervise Graduate Students at the Ladge Speech and Hearing Clinic at LIU/Post in Brookville, New York. Along with my wonderful business partner, Gail Weissman MA. CCC-SLP, and amazing programmers at Objectgraph LLC, I am also creating Apps designed specifically for our older clients.

As I am at the younger end of what would be considered the “baby boomer” generation, and currently working with adults who have begun to age and suffer communication disorders, I am particularly sensitive to the effect of aging and the social impact of communication disorders amongst this population.

As people get older, it is a fact that health and physical mobility are crucial elements in their ability to function in daily life, interact, and participate normally in society. Even older people who have simply aged with no other issues experience increasing isolation. Their spouses and friends move or pass away, leaving fewer opportunities for social interaction.

The baby boomers are aging and will become a large part of the population in the next 20 years. The Center for Disease Control in collaboration with the Merke Company Foundation has developed information on aging in America with a state by state assessment.

They listed 15 key indicators of older adult health:

  • Physically Unhealthy Days
  • Frequent Mental Distress
  • Oral Health: Complete Tooth Loss
  • Disability
  • No Leisure-Time Physical Activity
  • Eating ≥ 5 Fruits and Vegetables Daily
  • Obesity
  • Current Smoking
  • Flu Vaccine in Past Year
  • Ever Had Pneumonia Vaccine
  • Mammogram Within Past 2 Years
  • Colorectal Cancer Screening
  • Up-to-date on Select Preventive Services
  • Cholesterol Checked in Past 5 Years
  • Hip Fracture Hospitalizations

These factors have an impact on our aging family members ability to attend the therapies they need, maintain cognitive function, communicate and be self-sufficient. The majority of our elderly prefer to stay in a familiar environment even if it means living alone or with some outside help.

According to the United States Department of Health and Human Services Profile of Older Americans 2011, about 29% (11.3 million) of noninstitutionalized older persons live alone (8.1 million women, 3.2 million men), almost half of older women (47%) age 75+ live alone. The number of Americans aged 45-64, (I’m in that batch) who will reach 65 over the next two decades increased by 31% during this decade. Over one in every eight, or 13.1%, of the population is an older American. This demographic information along with changes in the federal budget and insurance reimbursement should be of concern to us, as professionals. Not only in terms of how we will make a living, but how will we be able to provide needed support and efficient services so that treatment approaches do not have to cost more money. Therapy can be more effective if we address communication and interaction within the framework of the aging living situation as a whole.

In one of the blogs on our website, I told a story of my own family experience. My grandmother, who was about 83 at the time, was placed in the middle of the livingroom while family and friends spoke to each other around her. (I was about 26 and a SLP for 3 years) She was able to hear well enough, and speak well enough, but the attitudes of the younger people were such that unless she made a ruckus, no one felt it was necessary to include her in the conversation! This isolation while surrounded by a bustling family, negatively affected her attention to her surroundings.

Part of my therapy approach with adult clients is to educate and include the families and caregivers in the therapeutic process as much as possible. Our family questionnaire includes questions such as: How many times do you talk to (our client) during the day. We also ask about the client’s speaking interactions at home or in a group of people. I have found that some family members want us to “fix” their husband or wife and want no additional responsibility. But we can talk to them to help them slowly understand that their situation will be better if they are aware of how they can help and use the adaptive tools we are giving them. We are not asking them to do the therapy or practice. We help them with resources in our community and teach them about paired communication and listening. The families, caregivers, even SNF staff should be encouraged to develop a communication routine that allows interaction not mere reaction.

There will be more on this topic in subsequent postings. Any of the Indicators of Older Adult Health frequency may impact our therapy attendance and reimbursement. What does this mean in terms of available services, advocacy, health care coverage, families and caregivers education/training? How can we, as Speech Language Pathologists recognize and support individuals and families in distress and facilitate communication awareness, not only with our clients who are coming for therapy, but for our aging population as a whole?

Betsy C. Schreiber, MMS, CCC-SLP, received a BA  in Psychology and MMS Master of Medical Science in Speech Pathology from Emory University in Atlanta, Georgia. Her CCC was earned during the 3 years she worked at Hitchcock Rehabilitation Center in Aiken, South Carolina where she had the opportunity to learn about NDT and Sensory Integration with the original, Jane Ayres, working with LD and CP children and neurologically impaired adults. She is currently a clinical supervisor at Ladge Speech and Hearing Clinic at LIU/Post on Long Island, and a partner at Hope 4 Speech Associates, P.C. She has also served as an ASHA Mentor and hopes to participate in ASHA’s  Political Action Committee in the coming year.