Speech

Language Pathology with the Aging Adult: Practice at the Top of Your License

Supplemental Resource/
Case Study Mary

Marie was referred to the SLP for a screen due to reports from the Physical Therapist that the patient, Marie, was demonstrating signs of word
finding impairments, impaired direction following and impaired memory. Therefore, the SLP initiated the screening process to determine if a full
evaluation was warranted.
Patient Identification/Physician Orders

During the PT session the SLP determined there were impairments with auditory comprehension for direction following of single and multi-step
commands. The SLP attempted to provide strategies to the PT to utilize to improve communication and the effectiveness of their sessions
together. The SLP continued to gather more information to determine what other, if any, areas of concern were present. The SLP completed
interviews with the nursing staff re: the current status of the resident compared to her prior level of functioning. As seen in the video recording
the clinician had a conversation with the Nurse while reviewing facts from the medical record and to learn what changes the nursing staff is
seeing in the resident, as well as, what has been documented in the nursing section of the medical record regarding a change in status. All of this
documentation provides additional support and justification for speech therapy services.
This case was discussed at the weekly case review meeting to ensure all aspects of Marie’s cognitive-communication needs were identified prior
to the SLP initiating the evaluation. Based on this meeting, the Nurse indicated that the resident intermittently demonstrated coughing during
medication intake of larger sized pills/medication and there was also evidence of a 3 pound weight loss. The PT and SLP discussed the results of
this screen with resident and spouse and both were in agreement to pursue this recommendation for a full comprehensive speech therapy
assessment.
Based on the results of the screening the Speech Language Pathologist, Bobby, did with Marie during the PT session and the results of the Brief
Cognitive Assessment Test – Short Form (BCAT-SF) that was completed by the Physical Therapist, the physician was contacted and orders for
speech therapy evaluation and treatment was made and received.
There are many components to the initial evaluation that must be completed prior to the SLP laying a hand on a patient. A thorough review of the
medical record must be performed. The chart review also includes a review of current medications, laboratory values, specifically related to
hydration status and nutrition status and also those related to pulmonary conditions, such as Arterial Blood Gas (ABG) levels to determine if
Chart Review

resident has Chronic Obstructive Pulmonary Disease (COPD). Additional information important to the SLP are consultative reports for any
instrumental assessments performed within the last 6 months. For example, results from a Chest X-ray (CXR), Magnetic Resonance Imaging (MRI),
Modified Barium Swallow Study (MBS), Fiberoptic Endoscopic Evaluation of Swallowing (FEES) would be beneficial for a patient with suspected
swallowing disorders.
Marie’s chart revealed a previous diagnosis of pneumonia. Included within her medical records was a copy of her chest x-ray depicting the fluid in
her lungs.

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 Speech Language Pathology with the Aging Adult: Practice at the Top of Your License

Supplemental Resource/
Case Study Mary

Robert continues to delve deeper into the case of Marie. Upon speaking further with facility staff, it was noted that Marie has recently begun
requiring increased assistance from caregivers and weight loss. This information paired with the previous diagnosis of pneumonia helped the
clinician determine that further assessment was required in the area of swallowing.
The Eating Assessment Tool (EAT-10) was provided to the resident and her husband. THE EAT 10 is a validated self-administered survey that
provides a subjective assessment of dysphagia. The tool poses various eating and swallowing scenarios, in which the patient must rate how
problematic each situation is, and to what degree, based on a 0-4 scale. The patient responds to 10 questions, and the numeric values are
assigned, with a value of zero indicating no problem at all, and a 4 indicating a severe problem. After the patient has rated each area, the total
Swallowing Assessment

number of points can be added, with a possible total of 40 points. An EAT-10 total score of 20 or over, indicates dysphagia is severely impacting
the patient’s quality of life and/ or a team approach may be warranted. If the average EAT-10 score is 3 or higher, the patient may have problems
swallowing efficiently and safely. It is recommended that the EAT-10 results be discussed with a physician. In examining the evidence, the EAT 10
has displayed excellent internal consistency, criterion based validity, and test-retest reproducibility. It can be used to track outcomes, as it can be
used at evaluation to document the patient’s perception of their dysphagia severity, and again at discharge to monitor patient response to
treatment and perception of improvement. Use of the EAT-10 with Marie yielded a core of 25 indicating oropharyngeal dysphagia.
An oral motor examination with a cranial nerves assessment was performed to gain more information regarding Marie’s swallowing difficulties.
Whenever a swallowing evaluation needs to be completed the clinician should start with a thorough oral mechanism evaluation with assessment
of structures and physiological movements of all structures, including the lips, tongue, velum, and larynx. The clinician should also assess facial
symmetry and sensory response to light and deep touch in order to ensure the sensory components of swallowing function are intact. Speed of
movements of lips and tongue movement is also very important during mastication and swallowing function, and therefore needs to be assessed
separately as well during the oral motor examination.
During the oral motor assessment for Marie It was noted that cranial nerve 10, the Vagus nerve was primarily affected as indicated by impaired
pitch change, a weak volitional cough, throat clearing and wet vocal quality post swallow.

The clinical bedside assessment was performed which revealed pharyngeal stage dysphagia characterized by coughing after the swallow of thin
liquids via consecutive cup and straw drinking and controlled cup drinking. No clinical signs of dysphagia were noted with nectar or honey thick
Swallowing Assessment

liquids or regular food textures. Upon completion of this assessment, the clinician trialed the use of throat clearing and the use of an effortful
swallow/push down technique to assist in airway closure and to determine if the signs or symptoms of dysphagia could be minimized. Both
Continued

strategies proved helpful in managing the patient’s ability to swallow safely and the clinician taught the patient these strategies.
Cervical auscultation was utilized during the bedside swallowing assessment as another form of auditory assessment of swallowing function. This
tool is used to assist the clinician in hearing whether there are changes in swallowing physiology as characterized by wetness in
inhalation/exhalation after the swallow, or to hear differences in swallowing sounds before, during and after the swallow.
A Modified Barium Swallow study was recommended to objectively assess swallowing function and rule out aspiration.

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 Speech Language Pathology with the Aging Adult: Practice at the Top of Your License

Supplemental Resource/
Case Study Mary

The 2nd session of testing was focusing on the assessment of cognitive-communication skills. The clinician began the assessment by performing
an otoscopic assessment to determine if there were any structural changes in the ears and in the middle ear that may require medical
management, such as cerumen build up, discoloration of the tympanic membrane, or fluid or other secretions in the outer or middle ear. As
stated earlier in this presentation, hearing loss can also be the underlying cause when a patient is labeled or diagnosed with confusion, and at
times referred to as demented. Therefore, this is an important component to the overall comprehensive assessment of speech, language and
Day 2 Evaluation: Cognitive-Communication Assessment

cognitive-communication skills.
The clinician then moved toward administration of the full Brief Cognitive Assessment Tool (BCAT) to check the “vital signs” of cognitive-
communication skills, and determine what specific cognitive-communication assessment would be most appropriate in the assessment process.
This standardized, evidence based screening tool is used because it has been validated on the aging patient population and provides the clinician
with scores indicative of either cognitive decline associated with aging, mild cognitive impairment, mild dementia, or moderate-severe dementia.
Marie achieved a score of 28. This BCAT total score is suggestive of dementia or significant cognitive impairment. The results of this assessment
revealed difficulty with orientation to state, city and situation; decreased in verbal fluency; impaired attention and cognitive shifting; dyscalculia;
decreased judgment; difficulty with immediate story recall; delayed story recall; difficulty with visual memory and difficulty recalling salient
details of a story presented verbally.
The Arizona Battery for Communication Disorders of Dementia (ABCD) was administered to the patient with results demonstrating a total overall
score of 19.35, indicating Mild Alzheimer's Dementia. Deficits also identified include decreased orientation to time, impaired word learning and
total recall at the word level, impaired verbal repetition at the sentence level, impaired reading comprehension at the sentence level, impaired
confrontational naming, impairments with concept definition and delayed story retelling skills.
Because this resident’s testing scores from the BCAT and ABCD indicated Mild dementia, It is imperative that the clinician determine where in this
disease process the patient is functioning to ensure an accurate plan of care is established. Using the Global Deterioration Scale, the clinician is
able to determine that Marie presents with characteristics of stage 4. Individuals functioning at GDS Stage 4 present with deficits that manifest as
decreased knowledge of current and recent events; deficit in memory of one's personal history; concentration deficit on serial subtractions;
decreased ability to travel to familiar locations, Inability to perform complex tasks, flattening of affect and withdrawing from challenging
situations occur and denial of condition. This is a common stage when we first encounter our patients with dementia in an assisted living
community because their problems are beginning to impact performance and they are at more risk to fall and break a hip or make serious
mistakes if living alone.

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 Speech Language Pathology with the Aging Adult: Practice at the Top of Your License

Supplemental Resource/
Case Study Mary

After reviewing the assessment results Robert must determine how much treatment is appropriate based on her deficits and abilities. To review,
the evaluation found that Marie demonstrates: Mild receptive/expressive aphasia: a mild-moderate cognitive-communication disorder and mild-
moderate pharyngeal stage dysphagia when consuming thin liquids.
It was determined that she required medically necessary skilled speech therapy services to improve receptive and expressive language, cognitive
Clinical impressions/prescription

communication and to reduce the risk of aspiration by improving her ability to swallow safely and effectively. Based on these deficits and the fact
that Marie has good support from her family and the facility staff, it was determined that a frequency of 3 times per week for 4 weeks was
appropriate to meet her needs.
A Modified Barium Swallow Study was also recommended and performed at the acute care facility. Results confirmed the clinician’s diagnostic
impression: trace laryngeal penetration with aspiration was evident during the swallow of thin liquids via controlled and consecutive cup drinking
due to reduced timing of laryngeal elevation and impaired airway closure. An effortful swallow technique was utilized which improved airway
closure and eliminated aspiration of thin liquids.
Marie is highly motivated to succeed and wants to remain as independent as possible within the assisted living environment. She has the support
of her husband, daughter and grandchildren who live nearby and will participate in therapy for caregiver education to help support Marie’s plan
of care. In addition, there are facility staff members including nursing assistants and activity personnel who are willing to modify their approaches
to help Marie succeed. Given these factors, Marie’s prognosis for achieving her goals is excellent. If Marie had limited support, the prognosis
might be more dependent on her ability to follow instructions and participate in home programs to encourage generalization of therapeutic
interventions.

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 Speech Language Pathology with the Aging Adult: Practice at the Top of Your License

Supplemental Resource/
Case Study Mary

Developing the plan of care and choosing appropriate goals is a patient-centered process. As such, the patient should be part of the clinical
discussion and goal writing process. The therapist must find out what personal goals the patient desires to achieve and prioritize them by need
and preference. Goals established specific to Marie include:
Communication Goals:
1. Patient will follow multi-step commands with 90% accuracy and verbal cues in order to understand directions during complex activities within 4
weeks.
2. Patient will accurately participate within conversation with 90% accuracy and verbal cues and visual cues in order to understand directions
during complex activities within 3 weeks.
3. Patient will improve reading comprehension of sentences to 95% accuracy with verbal cues and visual cues in order to use symbol
identification for comprehension of information within 4 weeks.
4. Patient will improve ability to name pictures to 85% accuracy and minimal Visual Cues in order to improve expressive language skills and
communicate complex needs/wants within 4 weeks.
5. Patient will improve word finding for generative naming to 85% accuracy and minimal descriptive cues in order to improve expressive language
skills and verbalize choices in everyday activities within 3 weeks.
Swallowing Goals: 1. Patient will increase airway protection with thin liquid consistencies to within functional limits with an effortful swallow in
order to safely swallow without s/s of aspiration within 3 weeks. 2. Patient will improve swallow initiation of thin liquid consistencies to 3 seconds
with oral/thermal stimulation in order to protect airway and reduce signs of aspiration within 2 weeks.
As you may have noted, all of the goals for Marie presented are measurable, objective, functional, relative to the patient’s deficits and time
based. These goals meet the criteria as laid out by CMS Guidelines.

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 Speech Language Pathology with the Aging Adult: Practice at the Top of Your License

Supplemental Resource/
Case Study Mary

Defining and defending the medical necessity of speech-language pathology services is essential for justifying the skilled interventions provided
and gaining reimbursement for those services.
Part of the critical thinking process includes determining the most appropriate level of care to provide each individual patient. Regulation
Medical Necessity

mandates that the amount, frequency, and duration of the services must be reasonable under acceptable standards of practice. As such, our
documentation must clearly demonstrate the clinical rationale behind choosing the frequency and intensity of our services. Our dose of
therapy must be in accordance with evidence based practice standards as well. As we reviewed earlier, utilizing resources from the ASHA
Compendium and Evidence Maps will assist the speech-language pathologist in determining the most appropriate frequency and duration of
intervention for individuals with varying health conditions. Documentation must clearly answer the questions, Why therapy? Why now? Why
by only a skilled clinician?
Goals and treatment approaches must be relative to the needs of the individual and a documented potential for improvement must be
evident. Our documentation must clearly depict the spell of illness, any exacerbation of medical conditions and any potential barrier or
facilitators of progress given the patient’s environment, activity and participation.

Answering these questions and documenting them well is consistent with the ICF or the International Classification of Functioning and Disability
Disability and Health

and Health Model (ICF). As clinicians practicing with the older adult we follow the WHO (World Health Organization/ICF Model to provide services
Functioning and
Classification of

to residents living in CCRC, AL and IL facilities. By adhering to this model, we are identifying a Health Condition and determining how we can
International

Model (ICF)

improve function, activity and participation within the resident’s living environment while taking into consideration the individual needs /
personal and external factors specific to each patient when establishing the POC.
These personal/external factors consist of: Age, Gender, Cognitive ability, Learning style, Cultural and language background, Physiologic reserves,
Disease state issues, Baseline capabilities as compared to age and gender norms for performance measures, Impairments, Activity limitations,
Participation restrictions, Environment, level of psychosocial support.

Dysphagia Intervention Session

Interventions for
EPB Dysphagia

Synchrony is a device used in the treatment of dysphagia, which combines the use of Patterned Neuromuscular Electrical Stimulation (PENS) with
surface electromyography (sEMG) biofeedback. However, sEMG can be utilized without the use of PENS, as seen in the treatment session with
Marie

Marie. Visual biofeedback is used to display activity from the muscles involved in swallowing. These measures are displayed as a signal that the
client can learn to manipulate, allowing the client to develop control over swallowing function. Swallowing exercises are practiced under the
guidance of a signal that provides information regarding the effectiveness of the exercise. sEMG biofeedback provides both the client and the
clinician with a means of evaluating and modifying the maneuvers and exercises during a dysphagia treatment session.

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 Speech Language Pathology with the Aging Adult: Practice at the Top of Your License

Supplemental Resource/
Case Study Mary

Compensatory strategies that would be beneficial include: spaced retrieval, use of visual aids, repetition/rehearsal, visualization, chunking and
errorless learning. We will discuss several of these strategies and how Robert chose the most appropriate interventions for Marie.
Metacognitive Strategy Instruction: Instruction including systematic explanations, elaborations or plans to direct task performance; verbal
modeling, questioning, and demonstration; reminders to use strategies or procedures; step-by-step prompts or multi-process instructions; dialog;
and fading cues. Steps may include: 1) Explicit practice 2) Orientation to task with visual schedule 3) Presentation of new tasks 4) Clinician
modeling of steps 5) Sequencing 6) Systematic probing and reinforcement.
Spaced Retrieval: Technique in which clinician asks a question that requires an immediate answer and time intervals for recall are systematically
increased. Verbal responses can be paired with demonstration of a procedure or skill.
Errorless Learning: Procedures that are structured to reduce the opportunity for errors during learning trials. Achieve by breaking the targeted
Cognitive-Communication Disorder Interventions

task down into units; modeling before target response expected, avoid guessing, immediately correct errors and purposefully fade prompts.
Errorless learning can be achieved via Forward and backward chaining.
Forward Chaining: Technique to teach multistep tasks beginning with the first step in the sequence, teaching each new step individually and
Evidence Based Practice

linking it sequentially to the next step. Progression to the next step is made as soon as the previous step is mastered.
Backward Chaining: Technique begins with the last step in the sequence and learns them in reverse order.
Vanishing Cues: form of backward chaining that provides the client with progressively weaker cues following successful recall of targeted
information.
Memory Aids/Systems: Instructional methods may facilitate active learning via declarative memory (e.g., imagery, verbal elaboration) or passive
learning via implicit memory (e.g., errorless learning, hierarchical cueing). Instructional methods can be either forms of direct instruction (e.g.,
breaking the target into discrete steps and sequentially completing a task) or strategy-based training (e.g., training the individual to develop
internal strategies that enable him/her to perform complex tasks). These are supported by different levels/types of cueing and practice dosage.
Selecting appropriate treatment approaches based on the principles of instruction facilitates more efficient learning of skills and strategies.
Used to facilitate participation in daily life activities and discourse. Requires activation of attention, semantic and episodic memory and language
concepts.
Memory Strategies: Chaining and Word/Mental Picture Associations for coding; Example: “Beach, Sand, Shells”; “When I say (cooking) you say
(stove); Recall visual and auditory information in increasing complexity; Use of Mnemonics for Memorization; Word List Retention, increasing
complexity; Name-Picture Associations to faces; Memory for numbers and sentences using chunking strategies (grouping into meaningful units);
Sorting and Remembering Categories; Reciting directions and following them of increasing complexity; read or listen to a paragraph of increasing
frequency, answering questions and retell the narrative; increase complexity by increasing sentence length; Memory and Mental Manipulation;
example read four words and then repeat in reverse order.
Reminiscence Therapy: Recalling personally experienced episodes from one’s past to create a sense of well-being. Context related to a theme
(work, vacations, music, marriage, etc.). Can include use of props, photos, music from era recalling.

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 Speech Language Pathology with the Aging Adult: Practice at the Top of Your License

Supplemental Resource/
Case Study Mary

The results of the ABCD and clinical observation in the patient’s natural communicative environment reveal a comorbidity of Aphasia. Evidence
based intervention approaches specific to Marie’s plan of care include:
Oral Reading for Language in Aphasia: Treatment using auditory, visual, and written cues to improve reading sentences aloud;
Evidence Based Practice
Aphasia Interventions

Promoting Aphasics' Communication Effectiveness (PACE)-Treatment designed to improve conversational skills using any modality to
communicate messages. Both the person with aphasia and the clinician take turns as message sender or receiver, promoting active participation
from the person with aphasia.
Life Participation Approach to Aphasia (LPAA): This approach includes Group therapy approach to aphasia that provides peer feedback and social
opportunities. Group treatment plan design includes an opening with a brief period of socialization prior to structured activities
Context Building: This approach uses leader-directed tasks to develop content, comprehension and confidence
Language Tasks: The patient is given opportunity to map language onto ideas that relate to a theme or skill
Discourse: Patients organize information from the session into functional discourse
Our goal through presenting the Exciting World of Speech-Language Pathology Practice with the older adult is not only to provide you education
regarding the critical thinking model, evidence base practice research, assessment and intervention, but also to share with you how rewarding it
can be to help the older adult achieve his or her goals and maintain their quality of life while aging in place. The field of speech-language
pathology is fulfilling. It requires a great deal of passion, dedication and expertise to be successful in providing clinical excellence to your patients
Closing

within the framework of best practice guidelines. It allows us to employ the knowledge and precision of a highly skilled medical professional in
the healthcare arena while integrating creativity and compassion throughout our everyday practice.

As you logged into the course, there were supplemental materials available for you to download. These were provided in order to locate the
plethora of resources on the American Speech Language & Hearing Association (ASHA) website related to Evidence Based Practice, and clinical
best practice. There is also a list of other registries that provide helpful information to help you implement quality evidence based clinical services
to your older adult patients. We hope that you enjoyed this course.

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