Interview with Susan Goldfein, Speech Language Pathologist
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Beck:Hi Susan, thanks for your time today.Goldfein:Hi Doug, thanks for inviting me.Beck:Susan, please tell me where you earned you degrees?Goldfein:My master's was from Hunter College in New York back in the 1970s in speech pathology and audiology, and I returned some years later for my doctorate. I
Beck:Hi Susan, thanks for your time today.
Goldfein:Hi Doug, thanks for inviting me.
Beck:Susan, please tell me where you earned you degrees?
Goldfein:My master's was from Hunter College in New York back in the 1970s in speech pathology and audiology, and I returned some years later for my doctorate. In fact, I earned my doctorate in 1991, from Teacher's College at Columbia, also in New York. My work at that time focused on the conversational interactions of married couples, when one of them has Alzheimer's Disease.
Beck:Very good, so you were actually ahead of the curve as far as the relationship between speech language pathologists (SLPs) and people with Alzheimers Disease (AD). As an SLP, what do you perceive as the primary needs of the AD patient?
Goldfein:Having access to a stage-appropriate communication facilitation environment as the disease progresses. For example, in the early stage of the illness, while communication remains functional, people with the diagnosis are troubled by word-finding problems and difficulty expressing their thoughts in well-formed sentences. At this stage, some people can benefit from therapy. As the disease progresses, and memory and learning further deteriorate, SLPs need to effectively communicate and articulate the abilities of the dementia patient to their family, friends and other health care providers. We need a health care climate which allows us to evaluate and prescribe appropriate interventions at each stage of the illness, from early stage through end of life, when we are dealing primarily with issues of nutrition and swallowing. In our recent ASHA presentation (November, 2005) we focused on the dementia patient in a congregate living situation, such as a nursing home setting, and intervention alternatives.
Beck:And in this context, you include not only AD patients, but other forms of dementia, too?
Goldfein:Yes, that's correct. However, the most common cause of dementia in the elderly is AD, and so that is the prominent diagnosis in this population.
Beck:What can you tell me about the intervention process for the SLP addressing AD patients? Are there patterns and protocols that are well defined and somewhat universal?
Goldfein:Not really. Techniques for working with people with AD and other dementias are still evolving. There are some standardized materials that are available that the SLP should be familiar with, like the Arizona Battery for Communication in Dementia, the Functional Communication Profile, Spaced-Retrieval, Memory Wallets, and training curriculums for caregivers like the FOCUSED program. SLPs should also be familiar with some of the more popularly used mental status questionnaires.
Beck:Do you do particular "memory work" with AD patients to try to enhance their short-term and long-term memories?
Goldfein:The technique that is being used and studied at this time is something called "Spaced Retrieval."
Beck:OK, and please define that for me.
Goldfein:Spaced Retrieval is a technique for helping people with memory deficits to remember basic pieces of information. For example, we know that AD patients in the mid-and-late stage will tend to repeat the same question over and over again. The patient may ask "What time are we eating lunch?" And then you might say "12 o'clock." And then a minute or two later, they might repeat the same question. Of course no one knows exactly why this behavior occurs. Perhaps they forgot they already asked, or perhaps they forgot your answer. Perhaps the question represents an inner anxiety because they cannot structure time? It could be any or all of these things, and more. The point is that the caregiver at home or in the nursing home gets frustrated, and then everything deteriorates. So spaced retrieval starts with the idea that people with dementia can still learn when we work with procedural memory, that aspect of memory that is most intact. So it builds on a preserved strength..
Beck:Can you give me an example?
Goldfein: Sure...well, let's use the question we just spoke about. Using the Spaced Retreival model, you might say to the patient "Lunch is at noon." And then you ask them 10 seconds later to recall the information, so you ask "When is lunch?" and if they respond correctly, you keep increasing the time intervals, so that eventually they can retrieve the information successfully on their own.
Beck:So then it sounds like there are successful cognitive strategies that SLPs can use to help the AD patient?
Goldfein:Yes, there are many examples of success while working with the AD patient, and one thing that really is helpful is using a screening process to select the most probable candidates for Spaced Retrieval and other rehabilitative techniques. One good resource for these and related techniques is the Myers Research Institute, and they're on the web at: www.myersresearch.org/difvis.html
Beck:Have you seen a change in the approach to long term care for the dementia patient in the USA?
Goldfein:Yes...In the last ten years, we've been slowly changing from the medical model of custodial care, to much more individualized approaches, and to better understand and respect the needs of the individuals. So we have progressed significantly, but we have a long way to go. There is a movement towards "Person Centered Care," which encourages nursing homes to best meet the needs of the residents, rather than best meeting the needs of the institution. In other words, the traditional model said everyone does this or that as a group, and in some respects the residents were treated like sheep...all herded to the same place or activity at the same time. As you probably know, Doug, 80 percent of the residents of nursing homes have some type of dementia, and so this shift to a person centered approach will continue to impact the way the dementia residents are treated, and it allows individuals to more adequately enjoy a quality of life that recognizes them as individuals. So there has been, and there is, an ongoing culture change. As SLPs we can be a very important part of this culture change movement by sharing what we know about communication and dementia and helping staff make each communication interaction with the resident one that will yield a positive result.
Beck:Is there a "downside" to the SLP participating in this change?
Goldfein:Well, one thing that is an issue is, of course, reimbursement. As SLPs it's sometimes difficult for us to bill for our time for all that we would like to do. The current reimbursement system does not permit this. The SLP working to improve the quality of life for an AD patient faces many pragmatic hurdles. I think we need to establish and execute some large outcomes-based studies to prove the efficacy and benefit of our interventions, and then I suspect reimbursement would be easier.
Beck:I think you're absolutely correct. If it could definitively be shown that SLP intervention reduces the need for professional or non-professional staff, or if quality of life (QOL) results were readily available showing an improved QOL for the AD patient, it would be easier.
Goldfein:Hopefully as a profession, SLP will soon conquer some of these challenges in the near future. As you may know, Doug, I am the coordinator of ASHA's Special Interest Division15-Gerontology, and we're addressing some of these same issues, too. Specifically, Division 15 is concerned with the interdisciplinary study and communication behaviors and disorders in older individuals.
Beck:Susan. Thanks so much for your time.
Goldfein:You're welcome, Doug. It's been my pleasure.
Recommended Resources
The ABCs of Dementia, Kathryn Bayles and Cheryl Tomoeda
Conversing with Memory Impaired Individuals Using Memory Aids: A Memory Aid Workbook, Michelle Bourgeois
Coping With Communication Chanllenges in Alzheimers Disease, Marie Rau
Alzheimers Disease Communication Guide: The Focused Program for Caregivers, Danielle Ripich
Successfull Communication with Alzheimer's Disease Patients: An In-service Manual, Mary Jo Santo Pietro and Elizabeth Ostuni
Dementia Reconsidered: The Person Comes First, Tom Kitwood
Goldfein:Hi Doug, thanks for inviting me.
Beck:Susan, please tell me where you earned you degrees?
Goldfein:My master's was from Hunter College in New York back in the 1970s in speech pathology and audiology, and I returned some years later for my doctorate. In fact, I earned my doctorate in 1991, from Teacher's College at Columbia, also in New York. My work at that time focused on the conversational interactions of married couples, when one of them has Alzheimer's Disease.
Beck:Very good, so you were actually ahead of the curve as far as the relationship between speech language pathologists (SLPs) and people with Alzheimers Disease (AD). As an SLP, what do you perceive as the primary needs of the AD patient?
Goldfein:Having access to a stage-appropriate communication facilitation environment as the disease progresses. For example, in the early stage of the illness, while communication remains functional, people with the diagnosis are troubled by word-finding problems and difficulty expressing their thoughts in well-formed sentences. At this stage, some people can benefit from therapy. As the disease progresses, and memory and learning further deteriorate, SLPs need to effectively communicate and articulate the abilities of the dementia patient to their family, friends and other health care providers. We need a health care climate which allows us to evaluate and prescribe appropriate interventions at each stage of the illness, from early stage through end of life, when we are dealing primarily with issues of nutrition and swallowing. In our recent ASHA presentation (November, 2005) we focused on the dementia patient in a congregate living situation, such as a nursing home setting, and intervention alternatives.
Beck:And in this context, you include not only AD patients, but other forms of dementia, too?
Goldfein:Yes, that's correct. However, the most common cause of dementia in the elderly is AD, and so that is the prominent diagnosis in this population.
Beck:What can you tell me about the intervention process for the SLP addressing AD patients? Are there patterns and protocols that are well defined and somewhat universal?
Goldfein:Not really. Techniques for working with people with AD and other dementias are still evolving. There are some standardized materials that are available that the SLP should be familiar with, like the Arizona Battery for Communication in Dementia, the Functional Communication Profile, Spaced-Retrieval, Memory Wallets, and training curriculums for caregivers like the FOCUSED program. SLPs should also be familiar with some of the more popularly used mental status questionnaires.
Beck:Do you do particular "memory work" with AD patients to try to enhance their short-term and long-term memories?
Goldfein:The technique that is being used and studied at this time is something called "Spaced Retrieval."
Beck:OK, and please define that for me.
Goldfein:Spaced Retrieval is a technique for helping people with memory deficits to remember basic pieces of information. For example, we know that AD patients in the mid-and-late stage will tend to repeat the same question over and over again. The patient may ask "What time are we eating lunch?" And then you might say "12 o'clock." And then a minute or two later, they might repeat the same question. Of course no one knows exactly why this behavior occurs. Perhaps they forgot they already asked, or perhaps they forgot your answer. Perhaps the question represents an inner anxiety because they cannot structure time? It could be any or all of these things, and more. The point is that the caregiver at home or in the nursing home gets frustrated, and then everything deteriorates. So spaced retrieval starts with the idea that people with dementia can still learn when we work with procedural memory, that aspect of memory that is most intact. So it builds on a preserved strength..
Beck:Can you give me an example?
Goldfein: Sure...well, let's use the question we just spoke about. Using the Spaced Retreival model, you might say to the patient "Lunch is at noon." And then you ask them 10 seconds later to recall the information, so you ask "When is lunch?" and if they respond correctly, you keep increasing the time intervals, so that eventually they can retrieve the information successfully on their own.
Beck:So then it sounds like there are successful cognitive strategies that SLPs can use to help the AD patient?
Goldfein:Yes, there are many examples of success while working with the AD patient, and one thing that really is helpful is using a screening process to select the most probable candidates for Spaced Retrieval and other rehabilitative techniques. One good resource for these and related techniques is the Myers Research Institute, and they're on the web at: www.myersresearch.org/difvis.html
Beck:Have you seen a change in the approach to long term care for the dementia patient in the USA?
Goldfein:Yes...In the last ten years, we've been slowly changing from the medical model of custodial care, to much more individualized approaches, and to better understand and respect the needs of the individuals. So we have progressed significantly, but we have a long way to go. There is a movement towards "Person Centered Care," which encourages nursing homes to best meet the needs of the residents, rather than best meeting the needs of the institution. In other words, the traditional model said everyone does this or that as a group, and in some respects the residents were treated like sheep...all herded to the same place or activity at the same time. As you probably know, Doug, 80 percent of the residents of nursing homes have some type of dementia, and so this shift to a person centered approach will continue to impact the way the dementia residents are treated, and it allows individuals to more adequately enjoy a quality of life that recognizes them as individuals. So there has been, and there is, an ongoing culture change. As SLPs we can be a very important part of this culture change movement by sharing what we know about communication and dementia and helping staff make each communication interaction with the resident one that will yield a positive result.
Beck:Is there a "downside" to the SLP participating in this change?
Goldfein:Well, one thing that is an issue is, of course, reimbursement. As SLPs it's sometimes difficult for us to bill for our time for all that we would like to do. The current reimbursement system does not permit this. The SLP working to improve the quality of life for an AD patient faces many pragmatic hurdles. I think we need to establish and execute some large outcomes-based studies to prove the efficacy and benefit of our interventions, and then I suspect reimbursement would be easier.
Beck:I think you're absolutely correct. If it could definitively be shown that SLP intervention reduces the need for professional or non-professional staff, or if quality of life (QOL) results were readily available showing an improved QOL for the AD patient, it would be easier.
Goldfein:Hopefully as a profession, SLP will soon conquer some of these challenges in the near future. As you may know, Doug, I am the coordinator of ASHA's Special Interest Division15-Gerontology, and we're addressing some of these same issues, too. Specifically, Division 15 is concerned with the interdisciplinary study and communication behaviors and disorders in older individuals.
Beck:Susan. Thanks so much for your time.
Goldfein:You're welcome, Doug. It's been my pleasure.
Recommended Resources
The ABCs of Dementia, Kathryn Bayles and Cheryl Tomoeda
Conversing with Memory Impaired Individuals Using Memory Aids: A Memory Aid Workbook, Michelle Bourgeois
Coping With Communication Chanllenges in Alzheimers Disease, Marie Rau
Alzheimers Disease Communication Guide: The Focused Program for Caregivers, Danielle Ripich
Successfull Communication with Alzheimer's Disease Patients: An In-service Manual, Mary Jo Santo Pietro and Elizabeth Ostuni
Dementia Reconsidered: The Person Comes First, Tom Kitwood