Transcript AAC Interventions for Individuals with Acquired Disabilities

CD 5672
Week 4
AAC Interventions for Individuals with
Acquired Disabilities
Summary of Chapters 15, 16, 17, 18, and 19
In Beukelman, , & Miranda, (2005). Augmentative and
alternative communication: Supporting children & adults with
complex communication needs (3rd Ed.) Baltimore, MD:
Brookes Publishing.
Chapter 15
Adults With Acquired
Physical Disabilities
Model for Intervention
• Communication needs can be based on several factors.
The three reasons to measure the intervention outcomes
are:
1. To consider the outcomes that have and have not been
met.
2. To document the effectiveness of the AAC agency and
services provided.
3. To measure the effectiveness of the agencies efforts.
Acquired Physical Disabilities
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Amyotrophic Lateral Sclerosis (ALS)
Multiple Sclerosis
Guillain- Barre Syndrome
Parkinson’s Disease
Brain- Stem Stroke
AMYOTHROPHIC LATERAL
SCLEROSIS
• Average onset is age 56
• ALS affects the motor neurons of the brain and spinal
cord, there is an unknown etiology
• Persons with ALS maintain their cognitive abilities
throughout the prognosis, however, there are changes in
cognition with their executive functioning skills.
• 14%-39% survive for five years after being diagnosed.
• 10% live up to ten years
• Median survival rate is 2.2 years
• Persons with dementia and ALS will also have more
severe problems including severe personality changes
and more cognitive breakdowns.
Communication Symptoms of ALS
• Between 75% and 95% of people with ALS are
unable to speak at the time of their deaths.
• Depending on the progression and type, speech
symptoms can vary
• Flaccid-spastic dysarthria are almost universally
present at some point
• Speech rate may decrease but intelligibility does
not until speech rate decreases to less that 100
words per minute
Cognitive/Linguistic Skills
• People with ALS generally retain cognitive and
linguistic function with progression.
• 40%-50% of those with ALS experience some
degree of dementia.
• 25%-35% of those without diagnosed dementia
will experience subtle changes in cognition.
• Cognitive deficits tend to be more prominent in
individuals with dysarthria and pseudobulbar
palsy.
• Evidence shows that progressive aphasia tends
to evolve into individuals with ALS.
Motor Skills
• Motor control capabilities effect AAC systems
• Bulbar ALS
– For some time people with this type can usually use a
device that they can touch with their fingers or hands.
• Spinal ALS
– These persons will typically have limb and trunk
weakness so they will need a device that involves
scanning of some type. During the progression the
need to change the device will occur several times.
AAC Devices & ALS
• Typically persons with ALS are open to AAC
systems but it is important to assess their
acceptance of the system for best use.
• Early introduction to AAC is key.
• If implemented after speech is lost, instruction
on how to operate a device becomes much
more challenging.
• An individual may always need facilitator
assistance to help maintain the device.
Intervention Staging
• Each stage relies more and more on AAC than the
preceding stage.
Stage 1: Minimal to no detectible speech disorder, may be
short, purpose of intervention is to monitor speech,
educate individuals with ALS, and acceptance of
disease.
Stage 2: Changes in speech rate due to fatigue, focus
intervention on minimizing environmental interference,
teaching strategies for establishing conversational
topics, making sure listeners are understanding of the
message, group conversations.
Intervention cont.
• Stage 3: decrease in intelligibility, intervention
should focus on slowing speech rate to
compensate, AAC device needs to be learned
and available to resolve communication
breakdowns.
• Stage 4: AAC devices become the primary
source of communication along with residual
natural speech.
• Stage 5: loss of all functional speech and rely on
AAC entirely, ventilators may be used for
respiratory support, swallowing difficulties may
occur.
MULTIPLE SCLEROSIS
• MS is a degenerative disease where there is multiple
plaques that cause destruction in myelin cells.
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Dysarthria is the most common among MS but is not present in all persons.
Although there are speech impairments, for most persons, AAC systems
are not required.
Aphasia can also be associated with MS causing language impairments at
different degrees for different people.
Visual impairment is also affected with MS, often being one of the first
symptoms.
Motor control problems vary significantly depending on the person and
progression. The limitations of MS that will be acquired must be assessed
with visual impairments when assessing for an AAC device.
Since progression is unknown it is hard to locate a device that will work for
long periods of time and assessment is difficult for the same reason.
The 5 classes of MS
1. Relapse and remitting- a person will have symptoms and fully
recover.
2. Chronic progressive- the symptoms progress over time becoming
more severe.
3. Combined relapse/remitting with chronic progressive- degeneration
of capabilities with times of remittance.
4. Benign- typical life span with little progression and typical
functioning.
5. Malignant- rapid deterioration of the cognitive, cerebellar, and
pyramidal systems that leads to death in a short amount of time.
Intervention Staging
Stage 1: No detectible Speech Disorder,
intervention should include education about
progression
Stage 2: Slight changes to speech, unstable
volume, and speech intervention is not
recommended yet.
Stage 3: Dysarthria appears and effects intelligible
speech, intervention is not required but
recommended to teach breakdown resolution
strategies.
Intervention Staging cont.
Stage 4: Experiencing significant reduction in
intelligibility, intervention includes speaking in
optimal listening conditions, alphabet boards are
commonly used during this stage.
Stage 5: Limited functional speech, rely on AAC
device for communication, implement yes/no
communication systems with caregivers,
individualized interventions are necessary.
GUILLAIN-BARRE SYNDROME
• GBS is a degenerative disease that is
characterized by progressive destruction and
regeneration of myelin sheaths in the peripheral
nervous axons.
• Paralysis begins in legs and moves upwards.
• Paralysis lasts from one to three weeks and the
myelin sheath regenerates and muscle strength
slowly returns, starting with the head.
• 80% fully recover.
Communication Disorders
• Flaccid dysarthria
• Anarthria (complete loss of speech)
• Severe paralysis requires ventilator
support
• Language and cognition is usually
unaffected.
Intervention Stages
Stage 1: monitor progression so AAC can be
provided when appropriate
Stage 2: respiratory support and AAC
intervention is needed, develop yes/ no
system
Stage 3: continue to use low-tech AAC devices
Stage 4: regain speech with reduced
intelligibility and loudness, continued
respiratory support
Stage 5: residual weakness, occasionally
dysarthria
PARKINSON’S DISEASE
• PD is caused by a loss of neurons in the basil ganglia
and brain stem. This causes many motor problems for
the person.
• Persons with PD typically have the ability to spell words
out for a device, but can have training to help with
memory and learning difficulties.
• Sensory skills are left unchanged.
• Side effects of L-dopa can interfere with AAC
approaches
• Motor symptoms include: resting tremor, rigidity,
reduction of movement (paucity), and impaired postural
reflexes
Communication Symptoms
• Dysarthria and dementia
• Speech symptoms include reduced pitch,
volume, increased rate, reduced intensity,
imprecise articulation
• No natural course of symptoms
• Gradually become increasingly difficult to
understand
Motor Skills
• AAC interventions should be aware of their
progressive motor impairments and create
the device accordingly
• Due to reduced ROM and speech, AAC
devices need to have a smaller display,
size, and keyguard for excessive
movement
• Lack of fine motor control will limit AAC
options
Assess Constraints
• Due to slow progression, people with PD
may be hesitant to use an AAC device
because at the time of onset, they can
speak
• People with PD have older peers and who
could have a poorer hearing, which would
cause a communication barrier
• People with PD blame the communicaiton
partner for not being understood
Intervention Stages
Stage 1: no speech difficulties, education and
acceptance of family, peers, and person
diagnosed
Stage 2: reduce volume, speech intervention
recommended, portable speech amplification
systems may improve communication
Stage 3: reduced intelligibility, reduced loudness,
increased rate, important to have frequent
communication partners to become more
familiar to speech
Intervention Stages cont.
Stage 4: no functional natural speech, AAC
boards can include pace setting boards,
alphabet supplementation to control
speaking rate.
Stage 5: loss of all functional speech, overall
motor control and cognitive impairments,
AAC devices are difficult to implement and
intervention is very individualized.
BRAIN STEM STROKE
• BSS is caused by lack of circulation around the brainstem
often causing dysarthria or anarthria.
• Persons with BSS’s communication symptoms differ
considerably depending on the level of disruption and
dysarthria.
• Tactile impairments typically occur with BSS
• Vision problems may or may not be affected; eye problems
may be affected if the stroke is high in the brain stem.
Communication/Linguistic and
Sensory/ Perceptual Skills
• If the stroke only
involves the brain
stem, no cognitive or
language impairment
is expected.
• If the stroke affects
more than the brain
stem, cognitive or
language impairments
may occur.
• Usually no cognitive
impairments
Motor Skills
• Usually experience problems with limbs.
• Difficulty controlling speech mechanisms
which would effect articulation and
intelligibility.
• Research shows eye or head pointing as
the alternative access mode is
successful as an AAC system.
Intervention Stages
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Since BSS not degenerative, the stages go
from worse to better in terms of therapy
Stage 1: provide early communication system so
they can at least answer yes/no questions
Phase 1- Initial choice making
Phase 2- Pointing
Phase 3- Multipurpose Electronic AAC device
Stage 2: develop voluntary control of respiratory,
vocal, velopharyngeal, and articulatory systems
while continuing to use AAC systems
Intervention Stages
Stage 3: intervention focuses on intelligibility
with goals of meeting all communication
needs through natural speech
Stage 4: no need for AAC device, goal of
intervention is to speak as natural as
possible by learning appropriate breath
groups and stress patterns
Stage 5: no detectable speech disorder,
very uncommon
Locked- in- Syndrome (LIS)
• Similar to BSS
• A basilar artery stroke, tumor, or trauma that
results in damage to the upper pons and
occasionally the midbrain causes a conscious
quadraplegic state that limits voluntary
movements to vertical eye movements and
sometimes eye blinks.
• Average survival rate of 85% is 5 years, ranging
from 2 to 18.
• Low and high-tech AAC devices can be
implemented.
• Angie H… refer back to printed ppts for
revision of this ppt…..
Chapter 16
Adults with Severe Aphasia
Aphasia
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“Aphasia is an impairment of the ability to interpret and
formulate language” (Garrett & Lasker, 2005, p. 467).
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Reduced abilities in speaking, auditory comprehension,
reading, writing, and gestural communication
Approximately 1 out of every 275 adults in the United
States have aphasia (Garrett & Lasker, 2005).
Most commonly results from Cerebral Vascular
Accident (CVA)
Other etiologies include: brain injury related to
accidents, tumors, or neurologic illnesses
Subtypes of Aphasia
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Wernicke’s
Broca’s
Transcortical
Anomic
Global
Treatment Approaches
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Traditional treatment
involves assisting people
with aphasia to speak more
effectively, comprehend
more fully, and write with
fewer errors
Participation Model focuses
on interventions that
enhance the person with
aphasia’s ability to actively
participate in life activities
that are important to them –
Patients are encouraged to
use natural communication
modalities and AAC
Functions of Communiation
– Analyze the purposes
of communication
prior to designing
AAC interventions
– Consider the four
general functional
categories:
expression of basic
needs and wants,
information transfer,
social closeness, and
social etiquette
Partner Dependent Communicators
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These communicators will always be
dependent on their conversational
partners for informational demands and
communication choices within familiar
contexts
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Emerging Communicator
Contextual Choice Communicator
Transitional Communicator
Emerging Communicator
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Characteristics
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Profound cognitive-linguistic disorder across modalities
Extreme difficulties speaking, using symbols, and responding to
conversational input
Seldom communicate purposefully or use nonverbal signs, such
as pointing or nodding
Intervention Strategies for Emerging Communicators
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May initially benefit from contextual activities that elicit referential
skills
Low-tech AAC devices can be used to help the emerging
communicator comprehend and control their environment
Treatment is focused on foundational communication skills: turntaking, choice-making ability with tangible objects or photographs,
referential skills, and clear signals of agreement or rejection
Conversation partner training should focus on how to provide
choice-making opportunities throughout daily routines and
reinforce communicator’s responses
Contextual Choice Communicator
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Characteristics
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More capable than emerging communicators, but do not
initiate or add to conversations on their own – socially
isolated
Can participate in conversations when provided written or
pictorial choices on a turn-by-turn basis
May benefit from Augmented Input Techniques
Intervention Strategies for Contextual Choice
Communicator
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AAC interventions should be embedded within
conversations about familiar topics
Primary expressive goal is to teach the communicator to
consistently reference what he or she is talking about,
understand the meaning of graphic symbols, make choices
to answer questions, and begin to ask questions by
pointing
Strategies for Contextual Choice
– Written Choice Conversation – the facilitator generates written
key words that are pertinent to a conversational topic.
Reponses can be general or specific.
– Yes/No Responses to a Partner’s Tagged Questions – Partners
add the phrase “yes or no” at the end of their questions coupled
with the corresponding head nod or shake.
– Asking Questions – May need additional interventions to initiate
conversations, such as hand-over-hand assistance to point or
gesture toward something or someone to ask questions
– Augmented Comprehension (Input) Techniques – especially for
the communicator with aphasia who also has auditory
processing difficulties: after the communication partner
identifies that the person with aphasia has misunderstood,
partner reiterates the message while simultaneously pointing to
the item being discussed, showing photographs, writing key
words or phrases, etc.
Transitional Communicators
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Characteristics
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Have strategies to convey their message when they are
unable to speak, such as search through their
communication notebooks or gesturing.
Biggest challenge is communicating successfully in
spontaneous conversations without contextual cues
Intervention Strategies for Transitional
Communicators
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Focus is on initiating conversations with as little cueing as
possible
Storytelling can be used as a content-rich communication
activity
Independent Communicator
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Can comprehend most of what is said to
them without contextual support; use
both natural speech and augmented
strategies
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Stored Message Communicators
Generative Message Communicators
Specific Need Communicators
Stored Message Communicators
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Characteristics
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Can independently locate messages that have been stored
in their AAC systems, without prompting in familiar settings
Seldom generate novel information in unusual topics (AAC
skills too limited to participate independently in free-form
conversations)
Intervention Strategies for Stored Message
Communicators
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Therapists and family members should work together to
store an inventory of messages for specific situations.
Intervention sessions outside of the therapy room, in
naturalistic settings, may be helpful to evaluate the
effectiveness of message content, etc.
Generative Message
Communicator
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Characteristics
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Maintain independent lifestyles
Preserved skills may include drawing, gestures,
pantomiming, first-letter-of-word spelling, word writing, and
pointing to words or symbols
Communication skills are often fragmented or inconsistent
and require some AAC intervention
Intervention Strategies for Generative
Communicators
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Focus on participation patterns, clarifying communication
needs, identify topics of interest, and teach the individual to
manage a variety of AAC strategies
Teach the generative message communicator when to use
the various AAC strategies – often overlooked
Specific Need Communicator
– Characteristics
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These communicators only need AAC in certain
situations for specificity, clarity, or efficiency
Often live independent lifestyles
– Intervention Strategies for Specific-Need
Communicators
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Analyze the requirements of the specific
communication task and contrast those
requirements with the communicators current
skills
May benefit from situation training (role play)
Assessment
– Evaluate communication needs, linguistic
and cognitive competencies
– Assess communication needs in real-life
contexts
– Assess Specific Capabilities
– Linguistic Skills
– AAC-Related Skills
– Nonverbal Communication Skills
– Motor Skills
Assessment cont.
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Sensory Skills
Perceptual Skills
Pragmatic Skills
Experiential Skills
Cognitive Skills
Assess Constraints
Partner Skills
Demands of Potential AAC
Strategies
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Motoric
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Cognitive
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Turning the device on/off, comprehending synthesized speech, using
flowchart menus, keyboarding, charging the device
Metacognitive
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Must memorize symbols (if used) – more novel than words
Numeric coding
Layers of arrays or boards – remember to look on each and the steps
to transition between, as well as where things are located without
having it represented in front of them
Spelling
Operational skills
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Writing, pointing, access to digitally stored messages
Using speech and writing, knowing when to use other strategies
Knowing when to rephrase a message as opposed to repeating
Repairing communication breakdowns with various AAC strategies
Linguistic
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Syntax & word-retrieval
Intervention Issues
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The following may affect success of an AAC intervention. This
is not an exhaustive list:
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The individual's or family's continued desire to work on speech
Difficulty with acceptance of AAC alternatives
Premature discontinuation of treatment
Poor matching between AAC system features and communicator's capabilities
Limited availability of personalized messages
Lack of practice in contextual situations
Lack of available communication partners for partner-supported communicators
An inadequate support network to assist in message development for generative
communicators
Lack of communication opportunities because needs are anticipated by others
Clinicians can work with the communicator and family
members about their hesitations using a device
Emphasis on conversation partner training should occur early
in an individual's recovery
Schedule routine follow-up visits each week, if possible
Chapter 17
Primary Progressive Aphasia
Primary Progressive Aphasia
• PPA is characterized by a gradual
regression/deterioration of language skills in the absence
of other types of cognitive impairments or other
behavioral disturbances for a period of at least two
years.
• PPA is the fifth most common type of dementia
• Some individuals with PPA may eventually show other
cognitive impairments that are more consistent with
other types of dementia (such as Alzheimer’s disease)
• Symptoms of PPA include:
– anomia (problems with naming)
– slow and hesitant speech
– fluent and nonfluent forms exist
Early Stage Intervention
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People in early stages of PPA are still able to use
some speech
People in the early stages show the most difficulty with
word finding
Intervention techniques are similar to techniques used
for “specific needs communicators”
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use of booklets or cards that contain specific information
pre-prepared questions that can be used for tricky language
situations
gestures for resolving communication breakdown
Middle Stage Intervention
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People with PPA in this stage are considered “generative
message” or “transitional” communicators
People in this stage may require AAC for most communicative
contexts
Persons in this stage may benefit from drawing in order to
communicate messages
Persons in this stage may find the use of: maps, calendars,
floor plans to be helpful for the clarification of specific content
related to their messages
Persons in this stage may also have problems comprehending
spoken information and so may require some augmented input
devices as well as devices/strategies for message generation,
these might include: printed key words, photos, gestures, etc.
Late Stage Intervention
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The communication needs of persons with PPA in
the late stages are similar to the needs of
“contextual choice communicators” in the initial
phases of this stage
These individuals need help both to communicate
and to comprehend information
As the disease progresses, these persons may
become “emergent communicators”. At this time,
they may require the use of interventions which use
limited choice making for the communication of
needs and wants
Communication Notebooks
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Communication notebooks are small wallets or note-books
which contain information that is personalized relevant to a
person’s communication needs
Communication notebooks or wallets may contain:
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photos of family members
if literate, may contain printed info that the person may normally
forget
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Notebooks should be personalized
Person with dementia or PPA should help the SLP decide what
content will be placed in the notebook before the disease
progresses
Opportunities for using the note-book and updating of content
should be a priority throughout the course of PPA
The notebook should be dynamic and adapted as the individual’s
communication needs change
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Dementia
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Dementia is described as a chronic, acquired
cognitive impairment
Diagnosis requires that the cognitive impairments
involve: memory PLUS one other cognitive domain
which might include: attention, language, praxia,
and frontal lobe functions, Alzheimer’s is the most
common form
Dementia affects:
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episodic memory- memory of recent events, effected first
semantic memory- memory for facts and general
knowledge
procedural memory- memory for how to do things, this type
of memory is preserved the longest
AAC Recommendations for
Dementia
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The primary focus of intervention throughout the course of the
disease is focus on strengths of the individual
General communication strategies for persons with dementia:
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Use of memory books (facilitates memory by utilizing recognition
rather than recall memory)
Reducing distractions- Persons with dementia may process
information more easily in distraction free environments
Organize information into manageable “chunks”
Provide information in multiple modalities (visual, auditory, etc)
Strategies should address both language representation and
organization
Environmental print/photos- when placed on commonly used
items, may remind person what the items are used for
Use a variety of strategies
Huntington’s disease
Huntington’s disease
HD is an inherited autosomal dominant degenerative
disease.
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Symptoms begin to appear around age 40
Persons with HD are often unable to speak functionally by
the end stages of disease (Folstein, 1990)
Primary symptoms include:
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spastic/irregular movement of the limbs/face
emotional problems
cognitive symptoms progressing to dementia with time
Communication impairments include:
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language comprehension deficits including high-level
processing difficulties
expressive language deficits
AAC Strategies for HD
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Speech may or may not be so impaired that it requires
AAC, dependent on stage of disease and individual
variation
Literature review suggests limited success with high-tech
AAC for persons with HD, as reported by Beukelman
(2003)
Text suggests low-tech AAC strategies that focus on
schedules and choice-making early in the course of
disease
Other suggestions include training communication partners
to cue/prompt persons using AAC consistently
Linguistic and cognitive supplementation is also
recommended (such as to-do lists, note-books describing
daily activities)
Chapter 18
Traumatic Brain Injury
TBI
• Until the mid-1990s, patients with TBI only used
AAC devices if they experienced severe,
persistent anarthria or dysarthria.
• Intervention with an AAC device is delayed until
the communication disorder ‘stabilizes’ after the
injury.
• Intervention focuses on short-term needs
instead of long-term so the patient can
communicate if he/she is in a rehabilitation
program.
Prevalence & Etiology
• Many temporary or permanent brain injuries go
unreported because the patient may only lose
consciousness for a short time and do not go to the
emergency room
• 1 in 6 reported TBI cases are unable to return to school
or work
• People at risk: between ages of 15-24 years and older
than 75 years
• Most common cause is motor vehicle accidents
• Second most common cause is fire arms
Cognitive/ Linguistic &
Communication Disorders
• Impairments in three areas:
– cognitive impairments
– language disorders
– communication disorders as a result of
damage to the motor control networks
• The communication disorder can change
greatly over the period of recovery
Natural Ability Interventions
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SLPs are not able to predict if the patient
will have natural speech recovery
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Topic Supplementation
Alphabet Supplementation
Portable Voice Amplification
Topic Supplementation
• If the patient’s speech is slightly
intelligible, a communication device that
provides context or a topic may be helpful.
Alphabet Supplementation
• Used for patients with dysarthria
• The first letter of each word is pointed to
on an alphabet board while saying the
word
• Allows the listener to focus on words that
begin with the letter
Portable Voice Amplification
• Some patients with dysarthria speech is
very quiet, therefore a portable speech
amplifier may be used
Assessment & Intervention
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Early Stage (Levels I, II, and III)
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Assessment
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Very difficult to assess because the patient may not be able to
stay awake or pay attention for a long period of time.
Very little formal assessment is used during this stage
The team documents changes and observations of the
patient’s responses
Gradually the person is able to differentiate between two or
more people or object-good sign of development of yes/no
responses
Intervention
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The first goal is to have the person awake and responding to
simple commands consistently.
Assessment & Intervention cont.
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Middle Stage (Levels IV and V)
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Assessment
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The patient will begin to specify his/her basic needs
May have a difficult time accepting the AAC intervention at this time because
of agitation and poor awareness of his/her communication deficits
At this time assessment is used to determine what the individual can do to
help achieve communication goals
This assessment is informal and nonstandardized
Seating and positioning is the main concern at this point
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This is important to determine if the patient can use direct selection or scanning
options.
AAC Intervention
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One or two major communication goals should be chosen at this time
The devices include nonelectronic: alphabet boards, pictures, word boards,
yes/no techniques, and dependent scanning
Communication partners are important at this stage
Assessment & Intervention cont.
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Late Stages (Levels VI, VII, and VII)
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Assessment
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Most individuals at this point have regained the cognitive
capability to be a natural speaker
Those who cannot speak- due to motor control disorders or
severe specific language disorders
AAC Intervention
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May have a difficult time learning new information
Natural speech usually has already come back before this
stage
AAC techniques in this stage are used for patients who have
physical or cognitive impairments.
The most important skill to regain is reading and spelling
Chapter 19
AAC in Intensive and Acute
Medical Settings
Intensive & Acute Medical Settings
• Acute and intensive medical units serve a wide range of
individuals who are unable to communicate, either
temporarily or permanently.
• Communication problems in these settings often occur
as a result of primary medical conditions such as:
traumatic brain injury, stroke, oral-laryngeal cancer, etc.
or as a side effect of interventions such as surgery,
intubation, and/or tracheostomy.
• People in acute settings need to communicate regularly
with hospital staff in order to participate in their own care,
as well as with family members.
Causes of Communication
Disorders in Acute Medical Settings
• CD in acute medical settings can occur as a
result of both primary causes and secondary
causes
• Respiratory support often interferes with
communication processes and a persona’s
ability to speak.
• Primary Causes- those directly related to an
individual’s illness or condition
• Secondary Causes- those related to an
individual’s need for temporary respiratory
support
Endotracheal Intubation
• Designed to transport air from a ventilator to an
individual’s respiratory system.
• Endotracheal tubes are usually passed in emergency
situations through the person’s mouth, pharynx, and
larynx into the trachea.
• Oral intubation interferes with communication in several
ways.
– First, because the endotracheal tube passes through the oral
cavity, it is impossible to articulate speech accurately.
– Second, because the endotracheal tube passes between the
vocal folds, which are located in the larynx, it is impossible to
produce sound.
Tracheostomy
• A tracheostomy is another way to transport air from a
ventilator to an individual’s respiratory system.
• It is a surgical opening from the front wall of the lower
neck into the trachea.
• An individual with a tracheostomy tube who depends on
a ventilator has limited natural speech because air
passes from the ventilator through the tube, rather than
through the oral cavity and past the vocal folds.
• Air passes in and out of the trachea via the tracheostomy
tube, bypassing the vocal folds so that no phonation is
possible and messages must be mouthed.
AAC Service Delivery in Acute
Medical Settings
• The core AAC team
generally includes a
speech-language
pathologist, a physical
therapist, and an
occupational therapist
who are employed by
the hospital.
Establishing an AAC Program
• The following equipment and materials should
form the basis for AAC interventions in acute
medical settings:
– a lightweight neck-type electrolarynx
– an oral-type electrolarynx
– materials to construct alphabet boards, word boards,
and picture boards
– several magic slates
– a portable mounting system on wheels to hold
cardboard message boards or eye-pointing displays
Barriers and Supports
• AAC teams must deal with a number of
practice or knowledge barriers including:
– Medical teams that do not refer individuals for
AAC services
– Personnel who prefer not to be burdened with
additional work in an already busy workplace
– Speech-language pathologists and other
professionals who are not familiar with
conducting AAC interventions in these
settings.
Screening
• The AAC team should conduct a preliminary
screening as the first step of an assessment to
determine whether the individual is an
appropriate candidate for a more complete
evaluation.
• The individual must be able to follow simple
directions and have some way of indicating yes
and no.
• Individuals who successfully complete
preliminary screening tasks undergo a more
extensive assessment of their capabilities.
People with Sufficient Oral-Motor
Control for Speech
• The first step in evaluation should be assessment of oral-motor
capabilities.
– If these are adequate to support speech, assessors should explore oral
communication options.
– If oral-motor control is inadequate, assessors must explore other
communication options.
• People that may not have the motor control necessary to produce
voicing will need one of two types of electrolarynx often serves as an
effective intervention device.
– A “neck-type” electrolarynx is positioned against the exterior neck wall
and vibrates the air column within the vocal tract.
– An oral-type electrolarynx delivers sound into the oral cavity through a
tube or catheter.
• The oral-type electrolarynx is useful for individuals who can’t use a necktype due to extensive tissue damage, swelling, or surgical tenderness in the
neck area or because they must wear cervical collars that obscure their
necks
Individuals with Insufficient OralMotor Control for Speech
• Writing Options:
– handwriting
– self construction of communication book
– “magic” slate so they can erase messages
• Options for People who cannot write:
– pointing with hands, eyes, or head to use direct selection
– alphabet board
– small typing system (individuals in an acute setting are unlikely
to have the time or motivation to use an encoding strategy)
– voice output if possible ( “voice banking” for children)
• Options for People who Cannot use Direct Selection:
– scanning options: dependent and independent
Access Constraints
• Funding: Fortunately, the same resources that are
responsible for hospitalization fees usually fund all
medicare-related services, including AAC services.
• Instruction of Listeners: The short-term acute medical
environment imposes quite extensive learning
constraints.
– First, individuals are very ill and under a considerable amount of
stress.
– Second, many professionals and others interact with these
individuals over the course of their stay.
– The most effective AAC interventions are those that require
minimal listener training. Individuals and their medical teams
tend not to use complicated AAC systems in short-term acute
medical environments