chapter 14 adults with acquired physical conditions
TRANSCRIPT
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Chapter 14 Adults with Acquired Physical
ConditionsIts all about communication
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Contexts in which AAC has Evolved
Context: More People with AAC Needs & AccessO Larger overall population
O Longer life expectancy for overall populationO Longer life expectancy for those with
developmental disabilitiesO Larger number of Children with disabilityO Larger population of people living with intubation
(and other temporary or permanent medical conditions)O Changing international access to technology with AAC
potentialAAC-RERC Partners: SOSC Report 2012
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The people: General Population Trends
O Increased lifespan– burgeoning older populationO People who live to 65 years of age are
expected to live 18.6 more yearsO (Women- 20 years; Men- 17.3 years)O (over 65 years: 2000– 12.9% of U.S.; 2030—
19.0%)O Life expectancy for people who live to 85
years is 6.8 more years for women and 5.7 more years for men.
Administration on Aging-based on US Census
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Context: Technology Shapes Ability and Disability
O New technologies can either mitigate or exacerbate disability
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Context: Rapid Technical Change
O Rapid technical change tends to emphasize universal design
O However, rate of change impacts the functionality of technology:O ElderlyO Those who require facilitator supportO Those with highly unique technical
requirements
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Technological Changes: AAC
O Mobile technologyO Creating communication spaces with shared
technological accessO Dynamic information gathering sharing to
support AACO New access strategies:
O Eye-head tracking in universal designO Integrating eye tracking and physical accessO Supported speech recognition of disordered
speech signalsO Brain computer interfaces that incorporated AAC
strategies
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Context: Use of Technology to Develop Capability
O Physical accessO Visual access and organization of
informationO Language and cognitive capabilityO Strategies
O GamingO Incremental increase in complexityO Sharing “space” with partners
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Context: Service Delivery/Policy Changes
O Mobile technology influencesO Change in support from commercial
providers of AAC appsO Declining rural populationsO Reimbursement per diem capsO Instructional support networksO Distance instruction and practice
support
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Need AAC Services (2 Examples)
Amyotrophic Lateral SclerosisO 5,600 diagnosed with ALS annually,
300,000 prevalenceO 80-90% people with ALS unable to speak
at time of deathO Median survival rates are 32 months from
onset and 19 months from diagnosisO Nebraska database 93% required AAC at
or before time of death(Ball, Beukelman, Pattee, 2004)
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Amyotrophic Lateral Sclerosis
O Bulbar SignsO Resulting from brain stem
involvementO Spinal signs
O Resulting from spinal cord involvement
O Mixed signsO Resulting from brain stem and spinal
cord involvement
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Symptoms and Natural Course Progressive Disease
O An ALS progresses, upper and lower motor neurons are involved
O Mean age of onset– 56 yearsO Male to female ratio—2:1O Bulbar ALS– women demonstrate more severe
symptoms than menO Spinal ALS—men demonstrate more severe speech
symptoms than womenO Language usually intactO Cognitive– 10% fronto-temporal dementia (more on
tests)O No important means of drug intervention
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SurvivalO 14 to 39% survive 5 yearsO 10% survive 10 yearsO A few survive 20 yearsO Those with primary bulbar symptoms
survive a median of 2.2 yearsO Death is usually from respiratory failure
due to infectionO Life is extended by invasive ventilation O Quality of life is improved with alternative
nutrition
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Communication Characteristics
O Gradual progression (speech symptoms)
O Dysarthria of mixed flaccid and spastic types (because of upper and lower neuron involvement)O Spastic dysarthria (upper)O Flaccid dysarthria (lower)
O Most cannot speak for some time prior to death
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Routine Intervention StrategyIntervention Phase 1: Monitor, Prepare, and
SupportO Monitor performanceO Make timely referralIntervention:O Confirm normalcyO Answer questionsO Identify service providersO Identify attitude patterns toward
communication impairments & technologyO Share speech monitoring results with
caregivers and other decision makers(Ball, Beukelman, & Bardach, 2007)
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Monitoring Speech Performance
O AAC interventions are difficult when person cannot speak
O Speech intelligibility is a poor predictor, because deterioration of speech can be very rapid
O Once speaking rate is 60% of normal, move toward AAC system (120-125 WPM)
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One person’s experience
O Sept: 97% intelligible, rate 90 WPM
O Nov: 75% intelligible, rate 68 WPM
O Feb: 33% intelligible, rate 52 WPM
O May: 6.8% intelligible, rate 36 WPM
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Late AAC Assessment Project
OPurposes:1. To identify persons with
amyotrophic lateral sclerosis (ALS) for whom the AAC assessment was delayed
2. To document the factors that result in a late AAC assessment
(Nordness, Ball, Fager, Beukelman, & Pattee, 2010)
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ParticipantsO 28 of 280 people with ALS were
identified as receiving a late referral (10%)
DemographicsGender Male= 11 (41%)
Female= 16 (59%)Onset type Bulbar = 16 (59%)
Spinal = 9 (33%)Mixed = 2 (7%)
Age at onset Mean = 59.87 yearsRange = 41-79 years
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Reason for Late AAC Assessment
10%
5%
10%
15%
20%
25%
30%
35%
General practitionerNon-Clinic NeurologistClinic NeurologistSNF/Group homeOther Health ImpairmentFamily IssuesTravelLanguage BarrierUnaware of ServicesPersonal Acceptance
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Intervention Phase II: Assess, Recommend, & Implement
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AAC AcceptanceOInitial acceptance– person with
ALS completed an AAC assessment, decided to obtain AAC technology and used AAC technology
ODelayed Acceptance– person with ALS initially rejected AAC
OReject– never accept
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ALS: AAC Acceptance and UseNebraska ALS Database (N=40)
O 95% unable to speak prior to deathO 96% accept AAC (6% delay; 4% reject)O All, who accept, use until within a month or
two of deathO Length of use is remarkably similar for
those with initial spinal (23 months) or bulbar symptoms (26 months) (these may be under-estimates because 15% continued to use while ventilated)
Ball, Anderson, Bilyeu, Pattee, Beukelman, & Robertson (2007)
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Reasons for RejectionOCognitive limitations of persons with ALS
OMultiple health conditions: Cancer & ALS
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AAC Acceptance by Gender
O AAC Acceptance Gender Differences
Male Female0
5
10
15
20
25
30
35
AcceptDelay AcceptReject
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Reasons for Delayed Acceptance
1. Resistance of Family Member
2. Resistance of physician3. Initial resistance of
person with ALS
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Intervention Phase III: Adapt and Accommodate
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AAC Technology Facilitators
Sister
Grandso
n
Brothe
rSo
n
Nursing Se
lf
Daugh
er0
102030
Comparison of Faciliation Involvement
Comparison of Faciliation In-volvement
Ball, Schardt, Kim, & Buekelman, 2005)
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Eye tracking Follow Up
O 15 persons with ALSO 14 Continued to use eye tracking
technologyO 1 discontinued (eye lid droop
interfered)Ball, Fager, Nordness, Kersch, Pattee, and Buekelman, 2010
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Reasons for Eye Tracking
O58% Eye gaze access onlyO27% Multiple access
preferredO13% Unable to scanO7% wanted eye and head
access
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Communicative Uses
Face
to Fa
ceGrou
pPh
one
Email Web
other
compu
ter fu
nction
s0
20406080
100
Percent of participants
Percent of participants
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Patterns of AAC Use (Routine Practice)
O Survey of family members and caregivers in 8 states (215 respondents—44.7%)O 79% reported difficulty with communicating
with others ( 65% with family member or caregiver)
O 45% reported having an AAC deviceO Communication Topic
O Personal needs– 73.3%O Caregiving Issues– 43.1%O Family Issues– 39.8 %O Comments about day– 33.1%O Pain—32%
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Brainstem ImpairmentOEtiology
O Brainstem stroke (basilar artery occlusion)
O Traumatic brain injuryO Brainstem tumorO DemylinationO West Nile/ Guillain Barre syndrome
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Clinical profiles1. Complete locked in
syndrome2. Incomplete LIS3. Transitioning from complete
LIS to incomplete LIS4. Top of Basilar Syndrome
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Complete LISO Early stages of recovery from
brainstem impairmentO Quadriplegia with intact or near-in
tact language/cognitionO Vertical eye movementsO Small number of individuals remain
chronically locked-in
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Incomplete LISOSevere physical impairments,
but not "locked in“OMay have ability to move ahead
or other body parts (control and stamina for these activities remain limited)
OHave more I control Or normalize control compared to complete LIS
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Complete to incomplete LIS
OGradual gain of physical movement control over time
ORecovery possible, but severe dysarthria, common in those who do regain some ability to speak
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Top Of the Basilar Syndrome
OLIS with impaired attention and arousal
OChallenging characteristics for effective AAC intervention
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Early/Acute Intervention
OMedical instabilityO Intervention needs to be flexible
and occur secondary to medical care needs
O Adjustments and intervention schedules (shorter but more frequent sessions)
O Education of care providers extensive component to early intervention
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Establish Consistent Response Mode
O Reliable yes/no response modeO Motor assessment