Transcript of Presenter: Masoud Rouhizadeh Seminar on Speech and Language Processing for Augmentative and...
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- Presenter: Masoud Rouhizadeh Seminar on Speech and Language
Processing for Augmentative and Alternative Communication Class 18:
User Issues Papers
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- 1) AAC for adults with acquired neurological conditions: A
review, Beukelman et al., 2007, Augmentative and Alternative
Communication. 2) The morphology and syntax of individuals who use
AAC: Research review and implications for effective practice,
Binger & Light, 2008, Augmentative and Alternative
Communication. 3) Memory aids as an augmentative and alternative
communication strategy for nursing home residents with dementia.
Bourgeoiset al, 2001, Augmentative and Alternative
Communication.
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- Paper #1: Beukelman et al. AAC for adults with acquired
neurological conditions: A review. A review of the state of the
science of AAC for adults with acquired neurogenic communication
disorders The topics of recent AAC technological advances,
acceptance, use, limitations, and future needs of individuals with
amyotrophic lateral sclerosis (ALS), traumatic brain injury (TBI),
brainstem impairment, severe, chronic aphasia and apraxia of
speech, primary progressive aphasia (PPA), and dementia are
discussed.
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- Acquired Neurological Conditions Adults with acquired
neurological conditions develop their verbal communication and
literacy capabilities as typical speakers and writers. Then they
gradually or suddenly lose their speech or language capabilities
and are required to rely on AAC systems to meet their communication
needs. In addition, the impact of their neurological condition on
their participation patterns is potentially profound with reduced
ability to care for themselves, a reduction or loss of employment,
and usually a sudden or gradual restriction of their social
networks.
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- 1) Amyotrophic Lateral Sclerosis (ALS) A rapidly progressive
neuromuscular disease of unknown cause and no cure. Initial
characteristics vary: brainstem symptoms involving speech and
swallowing, initial spinal symptoms involving the limbs, or a mix
of the two. The decision to use invasive ventilation extends the
length of AAC use overall, as well as the duration of time during
which AAC technology must be controlled with minimal or no limb or
head movement. Artificial nutrition, may extend the length of life
and could have an impact on AAC use: individuals spend less time
eating, have more energy, and have more time to participate in the
social activities of their choice.
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- AAC Acceptance and Use Approximately 95% of people with ALS
become unable to speak at some point prior to death. Prior to 1996,
approximately 73% of people with ALS used AAC Recently, 96% Those
who rejected AAC demonstrated a co-occurring dementia or
experienced multiple severe health issues, such as cancer, in
addition to ALS; Appropriate timing of referral for AAC assessment
and intervention continues to be a most important clinical
decision-making issue. Ball, Beukelman, & Pattee recommend that
individuals with ALS be referred for AAC assessment when their
speaking rate reaches 100 to 125 words per minute on the Sentence
Intelligibility Test (the mean is 190 wpm for normal adults)
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- AAC Acceptance and Use (cont.) A database review has documented
that family members with non- technical backgrounds typically serve
as AAC facilitators. Facilitator roles included mentoring and
coaching unfamiliar listeners about how to communicate with the
individual, programming messages, caring for equipment,
trouble-shooting, and communicating with the AAC interventionist.
These primary facilitators preferred hands-on, detailed
step-by-step instruction. AAC care-givers reported very positive
attitudes toward AAC technology. They reported increased perception
of social closeness to the individual with ALS and less difficulty
in providing care. Recent data from the Nebraska ALS Database have
revealed that individuals with ALS use their technology until
within a few weeks of their deaths.
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- Future Research Directions: Access Options A need for
technology that can be adjusted to meet a range of motor capability
demands. Dynamic touch screens Head-tracking technology Calibration
issues for individuals with limited range of movement. Eye-tracking
technologies: only effective under ideal situations Eye-tracking
technologies that operate effectively and efficiently under a range
of lighting conditions and postural conditions are still
needed.
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- Future Research Directions: Speech Synthesis Age range of
individuals with ALS who use AAC Age of other individuals who
reside in long-term care settings with some of these individuals A
continuing need for synthesized speech that can be easily
understood by elderly people in less than optimal situations As new
speech synthesis voices are introduced in speech generating devices
(SGD), the effectiveness of these voices in adverse listening
situations should be investigated and reported. The impact of the
naturalness of synthesized speech on the acceptance and use of SGDs
should be studied.
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- Future Research Directions: Access to other Technologies
Individuals with ALS present with a range of needs to use their AAC
technology to connect them to the outside world. Younger adults
with ALS use the Internet to maintain their social networks. First,
their generation has been active on the Internet since an early
age. Second, their spouses often must be employed and their
children are in school, which means there is limited support to
maintain social networks. Individuals with ALS continue to use
their AAC technology to program computers, do word processing,
provide accounting services, or consult over the phone or
Internet.
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- Future Research Directions: Facilitator Instruction AAC
technology facilitators for individuals with ALS are selected
largely because of their availability rather than their technical
expertise. Therefore, there is a continuing need for just-in-time
instruction to support them in their facilitator role(s).
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- 2) Traumatic Brain Injury (TBI) Extensive range of
communication disorders: cognitive/linguistic as well as motor
speech disorders. 55 59% recovered functional natural speech during
the middle stage of recovery. Those who were unable: chronic,
severe, motor speech or language disorders. Fewer people with
relatively preserved cognitive function and severely impaired motor
speech now than in previous decades. Given new medical
interventions, additional research is needed to predict those with
TBI who will and will not recover functional natural speech.
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- AAC Acceptance and Use High level of acceptance of AAC systems
Letter-by- letter spelling strategies, Their cognitive limitations
interfered with their ability to encode messages Some discontinued
AAC use because they had recovered natural speech, lack of funding,
and lost the support of an AAC facilitator. None of the
participants rejected AAC after receiving it
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- Future Research Directions Reducing the Cognitive Load for
Word/Message Prediction and Retrieval Nearly all individuals with
TBI prepare messages using letter- by-letter spelling Few reports
describing word prediction use Some were able to learn the encoding
or prediction strategy None of those taught used the strategy in
their everyday communication: It was "too much work" and that they
did not "think that way." Need for a means to retrieve words and
messages with reduced cognitive demands
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- Future Research Directions Supporting AAC Facilitator Learning
It is apparent that an effective AAC facilitator is critical for
continued successful use of AAC technology. The use of AAC
technology by some respondents was discontinued due to a lack of
consistent facilitator support during their transitions to
residential settings.
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- Future Research Directions Supporting the use of Residual
Natural Speech Individuals with dysarthria as a result of TBI
typically wish to use their residual speech to communicate.
Commercial speech recognition systems: Instructional strategies are
often too difficult Recognition accuracy is relatively low No
published reports of individuals with moderate to profound
dysarthria who use speech recognition to meet their routine
communication needs
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- 3) Brainstem Impairment Brainstem impairment damages the
central nervous system structures that control speech production.
Individuals with brainstem impairment often experience anarthria,
that is, they are unable to speak at all, or experience dysarthria
such that their speech is difficult to understand. Reports of
natural speech recovery vary from 0 to 25%. Nearly all of these
individuals require AAC support soon after the onset of this
condition, as most are unable to speak during the acute phase.
However, many rely on AAC due to chronic severe motor impairment
that may or may not be classified as locked-in syndrome.
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- AAC Acceptance and Use Direct selection: single finger or head
movement access Scanning: eyebrow, head, or hand movement Switch
access sites: head movements, mouth, fingers, and hands. Assistive
technology was used for communication, internet, email, writing,
telephone, games, vocational duties, and faxing. Safe-Laser
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- Future Research Directions Motor Learning to Restore Head
Movement or Body Movement Individuals with severe brainstem
impairment are able to learn head movements, sufficient to access
AAC technology, Ongoing research is needed to determine the extent
to which motor learning provides sufficient recovery of head
movement to allow for the use of conventional head tracking
technologies.
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- Future Research Directions Eye-Tracking Technology under Less
Than Optimal Conditions proper lighting precise positioning of the
technology limited residual head movement precise calibration
support
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- Future Research Directions AAC Systems Well-Connected to the
World Change in residence, loss of employment, and a shrinking of
ones social network. The Internet provides an opportunity to remain
engaged with family, friends, former colleagues, and others with
severe disabilities. Additionally, it supports educational,
recreational, and volunteer activities
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- 3) Severe, Chronic Aphasia And Apraxia Of Speech Aphasia is an
impairment that results from brain injury, usually due to
cerebrovascular accident, that may impair language production,
language comprehension, or both. Most people acquire aphasia after
the age of 60 or 70 years. Approximately one out of 275 elderly
adults in the United States has aphasia. Up to 40% of individuals
with aphasia have chronic, severe language impairment.
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- AAC Acceptance and Use Acceptance Often, those with severe,
chronic aphasia reject AAC secondary for fear of it interfering
with, or impeding, the restoration of their natural language system
Acceptance and attitude includes their family, friends, and peers.
Families often prefer natural speech for their loved ones People
less familiar with individuals prefer AAC strategies Both families
and peers were uncomfortable with the AAC strategies, because they
worried that the implementation of such an approach might impede
the return of natural speech. The authenticity of the messages and
stories stored in AAC systems is questionable Whether the
individual with severe, chronic aphasia actually authored the
messages?
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- AAC Acceptance and Use Low-Technology AAC Date back 30years and
include: communication and remnant books, drawing, photography,
written words, messages, and written choices The lack of
contextualization and personalization of communication books and
boards given with aphasia Commercially available communication
boards designed to facilitate communication about pain,
preferences, and health concerns They deemphasize the importance of
communicating to maintain social closeness, transfer new
information, and express social etiquette
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- AAC Acceptance and Use High-Technology Interventions
Lingraphica
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- AAC Acceptance and Use High-Technology Interventions Talking
screen
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- Visual Scene Displays in DynaVox
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- Future Research Directions Technology Commercial computer
software, digital photography, and Internet tools Impact of Context
on AAC Interface Use Messages are frequently co-constructed with
listeners The system must contain navigation strategies that can be
easily managed by both system users and their communication partner
VSD interface High-Quality Speech Output Integration of
Contextually Relevant Information into Traditional Aphasia
Interventions Acceptance and Use of AAC for Individuals with
Severe, Chronic Aphasia
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- 4) Primary Progressive Aphasia (PPA) PPA is now recognized as a
distinct clinical condition resulting in the gradual progression of
language impairment in the absence of more widespread cognitive and
behavioral disturbances for at least 2 years Rogers et al (2000) A
three-stage plan of AAC intervention that relies extensively on
low-technology AAC options: Communication notebooks consisting of
photos, icons, and collections of remnants that represent an
experience or an episode. Usually these items are accompanied by
printed names or messages to assist individuals with PPA and their
listeners.
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- 5) Dementia Dementia is a condition characterized by acquired,
chronic, cognitive impairment that may involve a variety of
domains, including executive function, attention, organization,
visuospatial function, praxis (movement) or language. 10% of people
aged 65 years and 47% of people 85 years and older diagnosed with
Alzheimers disease (AD), a form of dementia. 4 million people in
the US with AD; expected to be 14 million by 2050
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- AAC Acceptance and Use Interventions designed to remind them of
temporal or semantic information Computerized memory aids
Modifications of the communication partners behavior
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- Future Research Directions Lexical representation formats with
and without voice output High-tech multi- media system that
supports reminiscence interactions
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- Paper #2: Binger & Light, 2008 The morphology and syntax of
individuals who use AAC: Research review and implications for
effective practice, Binger & Light, 2008, Augmentative and
Alternative Communication. A research review of 31 studies
pertaining to the morphology and syntax of individuals who use AAC
and who had severe speech and physical impairments (SSPI)
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- Introduction Developing grammar skills is a complex part of
language development for individuals who use augmentative and
alternative communication (AAC) These individuals, many of whom
have severe speech and physical impairments (SSPI), rely on AAC
devices that typically contain graphic symbols (e.g., line
drawings, photo- graphs) and/or traditional orthography. Many
individuals who use aided AAC appear to have difficulty mastering
grammar skills
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- Paper Goals (a) To provide a systematic, comprehensive review
of the literature pertaining to the morphology and syntax of
individuals with SSPI (b) To discuss the implications of these
findings.
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- Criteria for Inclusion and Exclusion of Studies (a) primary
research studies published between 1985 and 2006 (journals and book
chapters) (b) studies that reported data pertaining to morphology
and/or syntax (c) studies that included either individuals who had
congenital SSPI or who did not have disabilities but used aided AAC
systems for research purposes. Morphology: the aspect of language
concerned with rules governing change in meaning at the intraword
level Syntax: organizational rules specifying word order, sentence
organization, and word relationships
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- Review Parameters Age and number of participants Disability
type Research design Language and/or cognitive functioning Type of
AAC system(s) utilized Aided AAC access methods Results of the
study.
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- Receptive Grammar Global measures of receptive grammar Eight
studies were conducted and involved 62 different individuals with
SSPI Some individuals received receptive grammar scores within the
average range for their chronological ages No consistent
differences were found between the participants who appeared to be
on target with receptive morphology and syntax skills versus those
who struggled with these skills with respect to the age of
participants, developmental level of participants, AAC systems
used, or degree of residual speech Global measures
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- Receptive morphology 19 children with SSPI (age range 417
years) Blockberger & Johnston, (2003): children who used AAC
had statistically significantly greater difficulty with the three
bound morphemes tested (past tense verbs, possessives, and third
person singular s) Redmond and Johnstons (2001): 3 children also
demonstrated difficulties detecting regular past tense verb errors.
However, they performed better with other grammatical markers,
including aspectual ing, subject verb agreement, and irregular past
tense verbs.
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- Tools and tasks used to assess receptive morphology
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- Receptive syntax Two studies The young adults in Lund (2001)
had difficulty with possessives and embedded clauses. Most
performed well on items assessing prepositions, negatives,
interrogatives, and coordinating conjunctions.
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- Tools and tasks used to assess receptive syntax
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- Expressive Grammar Global measures of expressive grammar:
Length of messages Young individuals predominantly produced
single-word (or very brief) messages when they used picture-based
AAC systems. Some individuals who use aided AAC systems produce
utterances containing more than one or two symbols The need to
include grammatical markers on AAC devices.
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- Expressive morphology Six studies included a total of 25
individuals Many individuals who use AAC can and do express a wide
range of morphemes but many individuals demonstrate morphological
errors Kelford Smith et al. (1989) One participant demonstrated at
least 90% accuracy for each morpheme type, Two others were below
90% for all but one morpheme type.
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- Expressive syntax Range and complexity of syntactic structures
Kelford Smith et al. (1989) 6 individuals used complex and/or
compound sentences Only two of the participants relied primarily on
simple sentence structures For complex sentences, accuracy levels
were all at or above 80% Only one participant obtained 100%
accuracy for compound sentences; the remainder ranged from 6 to
91%. In some other studies: the production of grammatically
complete simple sentences ranged from 0 to 98% Overall, the
expressive syntax findings revealed that many individuals were
capable of producing a wide range of syntactic structures, but
producing grammatically complete and correct sentences was
challenging for many of them
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- Expressive syntax: Word order Word order difficulties have been
reported both with individuals with SSPI and with children without
disabilities who used aided AAC for research purposes Sutton et al.
(2000) found that when adults without disabilities used AAC systems
that contained limited grammatical markers, they adjusted the word
order of sentences to avoid ambiguity
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- Grammar Intervention Using the participants AAC devices to
model the intended targets Bruno and Trembath (2006): some of the
children demonstrated post-intervention progress with acquiring
grammatical structures, although others did not. This indicates
that mastering grammatical structures may be quite time-consuming
for some individuals.
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- Discussion Many aided AAC users had difficulties with receptive
and expressive grammar Few consistent patterns emerged across the
studies Individuals with SSPI did tend to use brief, grammatically
incomplete messages to communicate. Because message creation via
AAC is usually a slow, laborious process for individuals who rely
on AAC, using brief utterances may reflect a choice of effective
language style, thus suggesting communicative competence, rather
than deficits Many of the studies in this review presented
relatively low levels of evidence. Out of the 31 studies, 20 lacked
any type of experimental control and reported only descriptive
measures Very few participants
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- Factors that may affect Grammatical Outcomes Intrinsic factors
that may affect mastery of grammar include developmental/cognitive
level, literacy level, motor capabilities, speech intelligibility,
and/or presence of a receptive and/or expressive language disorder.
1) the desire to promote communicative efficiency may help to
explain the high rates of single-symbol and telegraphic messages,
including the practice of message co-construction; 2) some of the
graphic symbols on an aided AAC device may represent multiple
concepts for an individual, thus negating the need to use multiple
symbols. 3) the input-output asymmetry inherent to most aided AAC
interactions: the person using AAC receives input via spoken
language but produces messages via multiple communication modes 4)
it is likely that an interplay of the factors listed above affects
grammar outcomes for many individuals with SSPI.
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- Discussion Implications for Practice Providing clinical
services to address grammar skills Assessment Tasks Conducting an
appropriate assessment that yields a clear picture of clinical
strengths and areas of need Intervention Techniques Models,
contingent queries, elicitation questions, recasts/expansions,
forced- choice alternative questions, corrections of incorrect
forms, and explanations of grammatical rules Many tasks that are
used for assessment purposes can also be used in intervention, such
as sentence completion tasks
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- Directions for Future Research (a) developing and evaluating
assessment tools to accurately and reliably assess receptive and
expressive grammar of individuals who use AAC; (b) developing and
evaluating intervention techniques designed to teach grammar skills
to individuals who use AAC, including those from diverse
backgrounds; (c) determining when grammar intervention is and is
not appropriate for an individual who uses AAC; (d) investigating
the impact that using aided AAC has on grammar acquisition; (e)
investigating the role that receptive grammar plays in the
acquisition of expressive grammar; (f) investigating the impact of
using various types of symbols on the expression of grammatical
markers.
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- Paper #3: Bourgeois et al (2001) Memory aids as an augmentative
and alternative communication strategy for nursing home residents
with dementia, Bourgeois et al (2001), Augmentative and Alternative
Communication. A research review of 31 studies pertaining to the
morphology and syntax of individuals who use AAC and who had severe
speech and physical impairments (SSPI)
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- Introduction Nursing home residents, often presumed to be
incompetent and dependent by their care givers, may be spoken to in
stereotyped ways that limit their chances for a meaningful
conversation and convey a sense of declining capability, loss of
control, and helplessness
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- Memory books Linguistically, memory books provide the semantic
content in the form of sentences, words, or phrases; pictures; and
access to additional semantic information stored in long-term
memory. Also, the written/graphic form may serve to bridge the
apparent comprehension deficits when directions and questions are
delivered verbally. Operationally, memory books capitalize on
preserved procedural memory skills, such as reading aloud, page
turning In the social domain, memory books capitalize on preserved
discourse strategies and a desire to communicate on the part of
residents with dementia As a strategic skill, memory aids are, by
their very nature, compensatory strategies that compensate for
memory loss and help to access stored memories.
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- The Dysfunctional Communication Environment The quality of
staff-resident communicative interactions is frequently described
as impoverished When there are communication problems in the
nursing home environment, there also tend to be problems with staff
morale, high rates of staff turnover, and quality of life issues
for residents Memory books, wallets, and cards have been shown to
improve the conversational abilities of persons with dementia In
this study it was hypothesized that nursing aides would improve the
quality of their conversational interactions with residents using
memory aids by asking fewer questions and decreasing other
nonfacilitative behaviors.
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- Method The effect of memory aids on conversations between
nursing aides and residents with dementia During 5-minute
conversations Nursing home units in seven nursing homes were
randomly assigned to treatment and control conditions. Residents in
the treatment condition were given 12-page memory books consisting
of autobiographical, daily schedule, and problem resolution
information. Their assigned nursing aides were trained to use the
memory books during care interactions and throughout the day.
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- Measures The duration and quality of verbal interactions
between dyads of a resident and their nursing aide during 5-minute
conversations were measured pre- and post-treatment
Computer-assisted observational techniques: The verbalization of
the resident (duration, percentage of time), The verbalization of
the nursing aide (duration, percentage of time), Positive and
negative statements (frequency), Memory book use (duration,
percentage of time). Verbatim transcriptions of videotaped
conversations Trained, Novel, Question, Ambiguous, Unintelligible,
Perseverative, Error, Other Quality of Life Measure The Geriatric
Depression Scale (GDS) N = 66; 33 treatment dyads and 33 control
dyads
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- Treatment and control groups Residents in the treatment group
were observed using their memory books during conversations 83.2%
of the time. Control group residents did not have memory books at
any time during the study.
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- Results Changes in Quantity of Nursing and Resident Behavior
Significant time group interactions as a result of the
intervention. Residents with memory books significantly increased
the number of utterances they used in post-training conversations,
compared with control residents.
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- Results Changes in the Quality of Conversational Interactions
Residents in both groups had similar changes in individual content
categories over time. Data were grouped into informative (novel +
trained utterances) and uninformative (ambiguous + perseverative +
error + unintelligible utterances) categories The second analysis
revealed a significant time group interaction for informative
utterances.
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- Results Effects on Quality of Life There were no significant
effects of the intervention on depression ratings over time for
either residents or nursing aides. After training, nursing aides
rated residents as less depressed than at baseline.
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- Discussion Nursing aides generalized communication skills
acquired in the care setting to a conversational situation without
additional training. The communication skills training + memory
book intervention was effective in changing the quantity and
quality of conversational interactions between nursing aides and
their residents with dementia. Specific facilitative patterns
emerged; nursing aides who reduced their percentage of
verbalization time and frequency of questions in response to
residents use of memory books had more equitable conversations with
those residents. Reduced nursing aide verbalizations appeared to
encourage increased resident verbalizations, an increased frequency
of resident utterances, and lower difference scores on resident and
proxy quality of life measures.
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- Future work Future interventions to improve the social and
communicative environments in nursing homes should incorporate
techniques to teach nursing aides: How to elicit conversations
about feelings, emotions, and opinions from residents with dementia
and How to respond in ways that promote a higher quality of life
for both residents and staff.
- Slide 71
- Thank you.