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Rehab Dialogue Preparing for the

“Rising Tide�

of Dementia: Charting a course for older Albertans

By Tammy Hopper, PhD, and Stuart Cleary, PhD

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Albertan turns 65 years old every 19 minutes. • Dementia is a condition of the elderly. Almost 40,000 Albertans have Alzheimer’s disease or a related dementia. • Speech-language pathologists can help older adults with dementia and other neurological disorders (e.g., stroke, Parkinson’s disease) by: o Providing assessment, training and treatments that improve communication between patients and caregivers o Increasing safety during eating and swallowing, to prevent choking and aspiration pneumonia o Ensuring patients have an accessible and reliable means of communication to make needs known, to socialize, and to participate in health-care decisions • In order to provide better care for Alberta’s growing senior population, we need more speech-language pathologist positions in Alberta.

Faculty of Rehabilitation FacultyMedicine of Rehabilitation | Rehab Medicine Dialogue| 2011 PageIssue 5 1

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Editor Laurie Wang

Design Radius Creative

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Photography U of A Marketing & Communications and Jimmy Jeong

SLP Rhonda Kajner with students assessing a resident in long-term care.

Meet Arnold Regal.* Arnold is an 82-year-old man with Parkinson’s disease and dementia living in long-term care. He had a swallowing disorder and was on a pureed food diet. He needed maximum assistance with eating, often needing to be fed. Arnold had a history of weight loss, losing about 15 pounds in 6 months. One day, Arnold choked on a sugar packet that he tried to eat as he had a habit of grabbing food items from his tablemates’ plates. A speech-language pathologist (SLP) joined his long-term care team and evaluated his swallowing ability and observed him during mealtimes. Over seven treatment sessions, the SLP worked with staff on appropriate strategies to increase safety during meals.

that prevented him from reaching and eating food items that were not on his plate.

The intervention involved teaching safe swallowing strategies, changing how the food was served, and compensating for Arnold’s cognitive problems by using a prosthetic device (a small, clear plastic barrier)

His grandchildren visit him frequently and no longer worry about Grandpa choking.

Thanks to the SLP and team, Arnold gained nine pounds over the subsequent two months. He was able to eat without as much staff supervision, had no further choking episodes and was more socially engaged with his tablemates.

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*Names have been changed. Resident not depicted in photo.

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SLPs meeting the needs of Alberta’s growing senior population • Communication disorders of dementia: Memory problems cause communication difficulties. People with dementia often forget their

Changing demographics Alberta’s population is aging. The first baby boomers (individuals born between 1946 and 1966) turn 65 years old in 2011 and according to the Seniors and Community Support, Government of Alberta website, one Albertan turns 65 years old every 19 minutes. Currently 10 per cent of the residents of Alberta are

considered seniors. In 20 years, this number will double to 20 per cent. Most older adults report good health; however, with advancing age comes an increased risk of developing certain health conditions that result in disability and limited participation in everyday life. One of these conditions is dementia.

own intentions, have difficulty communicating their needs and wants, and cannot understand the communication of others. Being unable to communicate can lead to social isolation, depression and a further negative spiral of mental and physical health problems. • Swallowing disorders: Also called dysphagia, caused by damage to muscles and/ or brain cells and nerves that control the mouth and throat. Problems swallowing can lead to choking, food and fluids getting into the lungs (aspiration), dehydration and

The “Rising Tide” of dementia Dementia is most often caused by Alzheimer’s disease, a progressive, degenerative brain disease. Symptoms include prominent deficits in memory along with problems in reasoning, judgment, communication and behaviour. As the disease progresses, affected individuals become unable to care for themselves. About half of those diagnosed with dementia live at home with support from family and home health care services. The other half live in supportive living, designated assisted living and longterm care centres.

some form of dementia; 40,000 of those individuals are living in Alberta. According to a report commissioned by the Alzheimer Society of Canada called, “The Rising Tide: The Impact of Dementia on Canadian Society” (2008), the prevalence of Alzheimer’s disease and related dementias will double over the next 30 years if a cure or prevention is not found. Researchers predict the demand for supportive living and long-term care will increase tenfold.

Dementia is a problem of growing significance. Approximately half a million people in Canada have

malnutrition. • Speech-language therapists can help improve the communication and swallowing abilities of older adults with neurological disorders, maximizing safety and independence, and reducing caregiver burden.

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What speech-language pathologists can do Speech-language pathologists are rehabilitation professionals trained in the science of communication and its disorders as well as swallowing and its disorders. SLPs have important roles to play in the care of Alberta’s elders, many of whom have dementia. Although there is no current cure for Alzheimer’s disease, there are evidence-based interventions to improve patients’ communication, eating and swallowing abilities. As part of our research program, we have focused on three lines of study and service related to communication and

local, provincial, national and international presentations, workshops and publications with a clinical focus.

swallowing care for older adults with dementia, stroke and other neurological disorders such as amyotrophic lateral sclerosis: 1. Conducting grant-funded research on outcomes of specific communication and swallowing treatments 2. Analyzing and classifying the research evidence for such interventions and writing best practice guidelines for speechlanguage pathologists 3. Translating research evidence into practice by regularly providing

From this research program, we found that there is a great need for SLPs to work with seniors. SLPs enable people to communicate effectively and eat and swallow safely. They assess, diagnose, treat, and help to prevent disorders related to speech, language, cognition, voice, fluency, and swallowing.

Dementia and communication Daisy Ragan* is an 85-year-old woman with Alzheimer’s disease who was living at home with the help of family. When she moved into long-term care, her family noted that she was not able to do things for herself like she did at home, and that she was frustrated when she tried to communicate with her new caregivers.

*Names have been changed. Resident not depicted in photo.

A speech-language pathologist assessed Daisy’s cognitive and communication abilities and systematically observed her interactions with her caregivers. The SLP taught caregivers specific communication strategies shown to be effective based on research evidence. These tactics were tailored to Daisy’s unique needs and situation. Positive outcomes included fewer frustrated interactions, decreased caregiver burden, and improved resident care during activities of daily living such as dressing, eating and bathing.

Demographic imperative – Addressing the rehabilitation needs of older Albertans As part of the Health Workforce Action Plan, Alberta Health Services supported expansion of the Master of Science SpeechLanguage Pathology program (MSc SLP) in the Faculty of Rehabilitation Medicine at the University of Alberta. The goal of the expansion was to address a longstanding and critical shortage of speech-language pathologists

in Alberta. More students were admitted to the program beginning in 2009. With an increased number of students came an increased need for clinical placements. Clinical placements with older adults were scarce in Alberta generally and Edmonton specifically. There were no speech-language pathologists working with older adults living in integrated community living

situations, including long-term care facilities. A partnership between the rehab faculty’s Department of Speech Pathology & Audiology and Alberta Health Services was created to provide a solution: SpeechLanguage Pathology in Integrated Community Living. Some of the goals of the partnership were to:

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provide high quality clinical placements with adult clients for U of A MSc SLP students; evaluate an innovative model of clinical education and to study the

effectiveness of the model; and create full-time speech pathology positions within Alberta Health Services Edmonton zone for adults where no service delivery previously

existed. These positions would be within three levels of care: facility living, community living, and home living.

Speech-Language Pathology in Integrated Community Living Speech-Language Pathology Consulting Services in Seniors Health – Edmonton Zone Communication Service Delivery Model

Client Referral Initiated

(Sources: Integrated Facility Living, Supportive Living, or Home Living)

Referral Source Contacted by Speech-Language Pathologist (SLP) • Needs assessment completed • Recommendations provided • Additional intervention determined if required (as below)

Client Specific Partner* Training • Audits

Increasing Awareness about the role of the SLP

• Brainstorm session with frontline staff

• Education regarding SLP service provision

• Knowledge and practice transfer sessions with client and/or staff

• Education regarding the general role of SLPs

• In-services

• Promotion

General or Theme-Based Training • Resource provision • In-services

Service Liaison • Referral to other health care professionals or centers

• Knowledge and Practice Transfer*

• Delegation, Collaboration, Follow Up (i.e. ALS Clinic)

• Workshops

• Training

• Co-Development of communication groups

Resource Development & Distribution

Family Groups • Education and support on dementia

• Information on finding resources (i.e. where to buy a pocket talker)

• Education and support on aphasia

• Development of info materials re: communication disorders

• Providing information regarding resources

Direct Consultation

• Screening • Formal assessments • Home Program • Partner Training • Audits • Trial treatments • Activity Participation • Environmental Adaptations

Follow up completed *Communication partner = family and staff caregivers Figure provided by Health Workforce Action Plan

The SLP in Integrated Community Living project has had successful outcomes: • Since January 2009, there have been 11 full-time and 26 parttime SLP student placements. • As a direct result of the project, four full-time speech-language pathology positions have been created. Prior to this project, these services were not available to clients living in an integrated community living setting within the Edmonton zone. • There were 187 client referrals to project SLPs between January

and December 2010 (65.2% Facility Living, 21.9% Home Care, 12.8% Supportive Living). Prior to January 2010, SLPs and their students provided services to more than 100 adults with communication and/or swallowing disorders. • SLPs and their students delivered more than 54 education sessions around high priority needs such as communication and dysphagia. These sessions were attended by approximately 500 individuals (facility staff, family members of residents, students from various health related disciplines).

• Students reported high quality clinical placements, with experience gained in several clinical areas; both students and SLP report benefits of using a new clinical supervision model. Expanding this project, providing clinical placements for SLP students to work with seniors and creating more full-time SLP positions in seniors facility living, community living and home living is a way to meet the needs of older adults in Alberta.

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Future directions The Alberta government recognizes the necessity of planning for the health-care service demands of older Albertans. By focusing on providing the “right care in the right place,” (Alberta Seniors and Community Supports), policymakers are continuing to develop an integrated seniors’ living strategy with a range of health care options, including rehabilitation services. In the future, speech-language pathologists should continue to be involved in integrated community living settings, including home care. Further, audiologists and technicians should be considered as consultant members of the rehabilitation team. There is a high prevalence of hearing loss among older adults that often goes underreported and under-treated. In fact, in the most recent report on Alberta seniors (A Profile of Alberta Seniors, September 2010), older adults listed hearing loss as one of the most common and disabling of the chronic conditions they face. As part of the Aging Population

Policy Framework developed by Alberta Seniors and Community Supports, the Government of Alberta plans to focus on supporting seniors in all facets of life, including their ability to maintain optimum independence in making decisions and being engaged in their communities. Being able to safely meet basic needs such as eating and swallowing, and to communicate with others, are key components of full participation in everyday life. The number of seniors in Alberta is expected to double in the next 20 years.

Speech-language pathologists have a unique skill-set to serve the needs of seniors in the community. There is a great need for more SLPs in integrated community living and long-term care. With four additional SLP positions working with seniors in Edmonton, we are definitely making headway. That being said, there is still much need, even in Calgary, and Alberta should lead Canada in providing the best care to our seniors. The University of Alberta’s Faculty of Rehabilitation Medicine and Department of Speech Pathology & Audiology are ready to work with the Alberta government to make that happen.

Researchers Stuart Cleary (back row) and Tammy Hopper (back row, far right) with SLP students, a long-term care resident, his wife and dietician (back row, far left).

About the Authors Tammy Hopper, PhD, is an associate professor in speech pathology & audiology at the University of Alberta’s Faculty of Rehabilitation Medicine. Her primary area of research is in treatment effectiveness of speechlanguage pathology interventions (memory and communication focused) for people with Alzheimer’s and other types of dementia. She also specializes in health care policy research as it relates to the provision of rehabilitation and nursing home care for seniors. Stuart Cleary, PhD, is an assistant professor in speech pathology & audiology at the University of Alberta’s Faculty of Rehabilitation Medicine. He is an adjunct assistant professor in neurology in the Faculty of Medicine & Dentistry. His research interests are in the areas of swallowing and swallowing disorders associated with aging and neurodegenerative disorders. Rehab Dialogue is a series of interactive articles published by the University of Alberta Faculty of Rehabilitation Medicine. We invite government, health-care professionals and the community to engage in a discussion on various health-care topics where rehabilitation could or should play a greater role, improving function, reducing pain, maximizing potential and quality of life—and sharing the vision for a healthy Alberta.

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Rehab Dialogue: Speech Language Pathologists helping to prepare for the "rising tide" of dementia  

One Albertan turns 65 years old every 19 minutes. Dementia is a condition of the elderly. Almost 40,000 Albertans have Alzheimer's disease o...