Come talk with me: improving communication between nursing assistants and nursing home residents during care routines.

PURPOSE: We examined the effects of communication skills training and the use of memory books by certified nursing assistants (CNAs) on verbal interactions between CNAs (n = 64) and nursing home residents (n = 67) during care routines. DESIGN AND METHODS: CNAs were taught to use communication skills and memory books during their interactions with residents with moderate cognitive impairments and intact communication abilities. A staff motivational system was used to encourage performance and maintenance of these skills. Formal measures of treatment implementation were included. RESULTS: Results were compared with those for participants on no-treatment control units. Trained CNAs talked more, used positive statements more frequently, and tended to increase the number of specific instructions given to residents. Changes in staff behavior did not result in an increase in total time giving care to residents. Maintenance of CNA behavior change was found 2 months after research staff exited the facility. Although an increase was found in positive verbal interactions between CNAs and residents on intervention units, other changes in resident communication were absent. IMPLICATIONS: Nursing staff can be trained to improve and maintain communication skills during care without increasing the amount of time delivering care. The methodological advantages of including measures to assess treatment implementation are discussed.

Functional outcome assessment of adults with dementia.

The demands from health care funding sources for treatment outcome data that will document the benefits of treatment relative to its cost have resulted in the widespread adoption of the World Health Organization International Classification of Impairments, Disabilities, and Handicaps as a useful model for gathering and providing such data. This article examines the literature on functional assessment and the outcomes of interventions for patients with dementia, then discusses current assessment instruments and procedures, the outcome data now available, and the research needs and challenges facing speech-language pathology in documenting the impairments, disabilities, and handicaps of patients with dementia.

Modifying repetitive verbalizations of community-dwelling patients with AD.

Seven caregivers of a home-dwelling spouse with Alzheimer's disease were trained during 12 weekly home visits to implement behavior management programs including written cuing procedures in response to repetitive verbalizations. Data from 7 trained caregivers and 7 matched control caregivers who only tracked repetitive behavior were compared. Results revealed that trained caregivers were successful at decreasing patient repetitions using written cues. Patients of control subjects showed no systematic changes in behavioral disturbances due to behavior tracking. In addition, intervention effects lasted for 16 weeks or longer and several caregivers reported applying the cuing intervention to other, nontargeted behaviors. Trained caregivers' perceptions of their efficacy in managing difficult patient behavior improved significantly at the 3-month follow-up assessment when program staff were no longer visiting them weekly.

When primary and secondary caregivers disagree: predictors and psychosocial consequences.

The purpose of this study was to investigate primary caregiving spouses' and their lay helpers' divergent opinions about the caregiving environment. Through parallel assessments, both primary and secondary caregivers of a patient with Alzheimer's disease were asked to rate the degree of patient problem behaviors; the degree of strain the primary caregiver was experiencing; and primary care-giver efficacy, or perceived ability to cope with caregiving demands. Analyses concentrated on the general levels of disagreement in these domains, as well as on potential predictors and consequences of such disagreement. Results revealed a substantial divergence in perceptions across caregiving domains, with relatively less disagreement about patient problem behaviors and primary caregiver strain than about primary caregiver coping efficacy. Primary caregivers with relatively pessimistic secondary caregivers experienced relatively less psychosocial distress than primary caregivers with more optimistic helpers. These findings were strongest among female-female caregiving dyads. Theoretical implications and methodological limitations of the study are discussed, along with suggestions for future research.

Interventions for caregivers of patients with Alzheimer's disease: a review and analysis of content, process, and outcomes.

Current reviews of the caregiver intervention literature have focused primarily on the outcomes of interventions for caregivers and general methodological limitations of individual studies (i.e., sampling and recruitment issues, adequacy of outcome measures, and generalization issues). Little attention has been paid to the specific factors affecting the therapeutic process, including the intensity and integrity of the interventions used. The purpose of this review is to examine closely the content and process of Alzheimer's disease (AD) caregiver interventions. We describe the types of interventions currently in use, factors affecting intervention outcomes, and we conclude with specific recommendations for the application of intervention technology and for the documentation of intervention research.

Effects of memory aids on the dyadic conversations of individuals with dementia.

The effects of a prosthetic memory aid on the conversational content and social skills of dyads with dementia were evaluated. Six individuals with moderate to severe dementia served as either subject or partner in dyads during 5-min conversational probes conducted three times per week in day-care and nursing-home settings. During phases when a memory aid, consisting of personally relevant picture and sentence stimuli, was available, most subjects used their own aid to improve the quality of conversations by increasing the frequency of on-topic statements, diminishing nonproductive utterances, lengthening their conversational turn, and/or increasing the frequency of turns taken. Most partners demonstrated awareness of social discourse conventions by appropriately relinquishing conversational dominance, decreasing both content and nonproductive utterances, and increasing acknowledging or affirmative comments when subjects used memory aids. Naive judges' ratings of aided and unaided conversational samples on seven conversational dimensions reflected differences in perceptions of significant improvement as a function of the conversational discourse style of each dyad.

Evaluating memory wallets in conversations with persons with dementia.

The use of memory wallets to self-prompt factual information during prompted conversations with familiar partners was evaluated for 9 subjects with dementia. Memory wallets contained 30 pictures and sentences about familiar persons, places, and events that each participant had difficulty remembering. The amount of training by caregivers was the one component of the intervention package that varied among the nine attempts to replicate condition effects observed on introduction of the wallets. All subjects learned to use the memory wallets to improve their conversations by making more accurate factual statements. Even when caregiver training was not provided to 3 subjects, condition effects were still demonstrated, with only 1 subject requiring a brief orientation to his wallet. Long-term maintenance of condition effects was demonstrated for 3 subjects up to 30 months' postintervention. These results support the clinical utility of a memory wallet intervention package for persons with dementia and provide preliminary evidence that often little more than preparing memory wallets and providing a brief orientation are required to facilitate their use in improving conversations with familiar conversational partners.

Communication treatment for adults with dementia.

Intervention studies reporting improvements in communication skills in aging adults presumed to have dementia were identified and reviewed. Whereas the speech-language pathology journals have published only articles on the diagnosis and identification of communication deficits in adults with dementia, over 100 articles on treatments effecting changes in communicative deficiencies were found in psychology, social work, nursing, and gerontology journals. Much evidence supports the potential for positive outcomes from communication treatment with this population. Various design and methodological flaws, however, limit the extent to which these interventions should be applied without further research. Issues of ethics and social validity are discussed, and treatment and research needs are outlined.

Enhancing conversation skills in patients with Alzheimer's disease using a prosthetic memory aid.

The effectiveness of teaching Alzheimer's disease subjects to use a prosthetic memory aid when conversing with familiar partners was evaluated. Effects of the training of three topics by caregivers was assessed in daily probes with the experimenter and twice weekly probes with a familiar conversational partner. All 3 subjects learned to use the memory aid with both conversational partners and improved the quality of their conversational content. Subjects made significantly more statements of fact and fewer ambiguous utterances after training on each topic according to a multiple baseline design. All subjects also generated novel, untrained statements in conversations with both partners. Treatment effects were maintained at high levels throughout training and at 3- and 6-week follow-up sessions. Naive judges rated baseline and posttreatment conversational samples as significantly improved on all eight conversational dimensions.

Facilitating generalized requesting behavior in Broca's aphasia: an experimental analysis of a generalization training procedure.

The effects of a generalization training procedure on requesting by 4 subjects with chronic Broca's aphasia were examined using a multiple baseline design across behaviors and subjects. Subjects were trained to request information on three topics sequentially. Generalization across topics and persons was assessed in weekly probe sessions consisting of 5-min conversational interactions with trainers and unfamiliar volunteers in a nontreatment setting. Results revealed generalization effects were greatest when trainers, as opposed to unfamiliar volunteers, served as conversational participants. Nevertheless, subjects' requests increased with all conversational participants to a level comparable to a normal comparison group assessed under conditions identical to the experimental probes. Social validation of treatment effects using a subjective evaluation procedure revealed significant improvement on the parameters of talkativeness, inquisitiveness, and conversational success.

Experimental analysis of syntax training in Broca's aphasia: a generalization and social validation study.

A multiple baseline design across responses was used to examine the effect of syntax training on the sentence production of 4 individuals with chronic Broca's aphasia. Subjects were trained to produce five exemplars of five sentence types from Helm's Elicited Language Program for Syntax Stimulation (Helm-Estabrooks, 1981). Generalization and maintenance of trained sentence types to novel exemplars and novel stimulus conditions served as dependent measures. In addition, five naïve judges rated subjects' responses before and following the treatment in terms of their "adequacy." Generalization to novel exemplars was demonstrated sequentially by 3 subjects (i.e., following the teaching of all five forms), and the remaining subject demonstrated generalization for three of five sentence types trained. Maintenance was variable across subjects and sentence types. Generalization across stimulus conditions was limited for all subjects. Adequacy judgments revealed improved communication skills for wh-questions but limited changes in the perceived adequacy of subjects' declarative responses. These findings indicate that the effects of syntax training procedures are limited to those grammatical constructions taught, that generalization of learned forms to novel stimulus conditions is not an automatic consequence of acquisition, and that the effect of such training on the adequacy of subjects' responses may be limited.

Visual and tactual perception of syllable number in sentence stimuli.

The purpose of this study was to determine whether suprasegmental information could be perceived by artificially deafened subjects via the Multipoint Electrotactile Speech Aid (MESA) so as to enhance the visual perception of connected discourse. This study compared subjects' untrained ability to perceive the number of syllables in sentence stimuli in three conditions: Visual Alone (VA), Tactile Alone (TA), and Tactile plus Visual (TV). Five adults tapped the temporal pattern of stimuli using a telegraph key. Stimuli consisted of 1-, 3-, 5-, and 7-syllable meaningful sentences and 5- and 7-syllable (nonmeaningful) second-order sentences. The subjects perceived correctly a mean of 37% of the stimuli in the TA condition, and approximately 60% of the stimuli in the VA and TV conditions. Three possible explanations are offered to account for these results: (1) the limitations of the MESA's electrocutaneous transform of the speech signal, (2) the sensory limitations of the skin, and (3) the absence of extensive training.