Why are we here? 2017 Hallowell... · Strengths-Based Perspectives Brooke Hallowell Hallowell, B. (2017). ... An important approach led by the WHO to classify functional areas of

Brooke Hallowell April 2017

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Language in the Context of Aging:Strengths-Based Perspectives

Brooke Hallowell

Hallowell, B. (2017). Aphasia and other acquired neurogenic language disorders: A guide for clinical excellence. San Diego,

CA: Plural Publishing. ISBN13: 978-1-59756-477-9

Why are we here?



What are important things to consider when talking and writing about older people and people with disabilities?

Why do words matter?

● Not just a matter of political correctness● Enhance sensitivity and awareness● Advocate for people with disabilities

General terms

● “Disability” generally accepted, but definitely not by all

● “Handicap” generally less accepted● Other options:

● Special needs● Differently abled

Person-first language

● Person-first language: Refer to the person first● Never use a disability label as a noun

An autisticA man with

autism


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The disabled People with disabilities

An aphasic A person with aphasia

A paraplegic A person with paraplegia

REFERRING TO OLDER PEOPLE

� Person-first applies� Not “the aged” or “the elderly”

� What about senior citizen? Or senior?“Admen and Coma (2009): “After all we don’t refer to people under age 50 as ‘junior citizens.’ Instead say ‘man’ and ‘woman, and give their age, if relevant…” (p. 36).

� People under 55, on average, are not bothered by the terms elderly, retiree, and senior citizen; however, those over 55 are.

� What about:� Golden ager, golden years, age of maturity?� Cute, spry, miserly, doughty, or cranky?� 95 years young� Grandfatherly type� Sweet little old lady

WORDS CONSIDERED TO BE “OBVIOUSLY AGEIST” IN THE INTERNATIONAL LONGEVIT Y CENTER-USA AND LEADING AGE

CALIFORNIA ST YLE GUIDE ( A D M E N & C O M A , 2 0 0 9 )

AncientBiddyCodgerCootCroneCrotchety old manDirty old manFogyFossilGeezerHag

Little old ladyMiserly old manOld fartOld fool Old goatOne foot in the graveOver the hillPruneSenile

• Are there some you have used yourself? • Are there some for which you plan to refrain from using ?• What are some constructive ways to counter the use of ageist terms?

HOW WOULD YOU REVISE THESE STATEMENTS?

�Ms. DeRose is a spry 90-year-old paraplegic.� I have three TBIs in my cohort.� It is unclear if the grandmotherly demented woman was

withdrawing socially because of her general crotchetiness or because of clinical depression.

�Subjects in this research were 30 elderly aphasic patients from the community.


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WHAT IS AGING?

�Aging is an ongoing process

�Ways of defining age oChronological ageoBiological ageoCognitive ageoPsychological ageoSocial age

Source: “Project Grandma” by Vinoth Chandar, licensed under CC BY 2.0.

WHAT DOES IT MEAN TO BE “OLD”?

WHAT IS AGING?

� Ways of defining age o Chronological age

� An index of how long a person has lived since birth

o Biological age� An index of the functioning of one’s bodily

organs over time [video exploration] [Do we have to get old and die?]

o Cognitive age� A index of how one’s cognitive abilities

change over time

o Psychological age� An index of how one’s personality changes

over time

o Social age� An index of aging according to one’s social

roles as well as environmental changes Source: “Project Grandma” by Vinoth Chandar, licensed under CC BY 2.0.

US CHRONOLOGICAL DIVISIONS OF OLD AGE

�Oldest-old: 85+�Old-old: 75-84�Young-old: 65-74

WHAT ARE KEY THEORIES ABOUT AGING THAT ARE ESPECIALLY RELEVANT TO COGNITION AND

COMMUNICATION?

WHAT A RE KEY THEORIES A BOUT AGING THAT A RE ESPECIALLY RELEVANT TO COGNITION A ND

COMMUNICATION?

�Biopsychosocial models of aging�The life-span model of postformal

cognitive development (Schaie, 2005; Schaie & Willis, 2002)�Motivational theory of life-span

development (Heckhausen, Wrosch, & Schulz’s, 2010)


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WHAT A RE KEY THEORIES A BOUT AGING THAT A RE ESPECIALLY RELEVANT TO COGNITION A ND

COMMUNICATION?

�Biopsychosocial models of aging�World Health Organization International Classification of Functioning, Disability and Health

WHAT IS THE WHO ICF?

� A conceptual framework (not a model)

� A system for classifying health and health-related domains for clinical and research applications in a consistent way throughout the world to classify health conditions, not people ( T hr e ats , 2010)

� An important approach led by the WHO to classify functional areas of health and disability

Communication

Interpersonal Interactions

Relationships

Domestic Life

Community Life

Social Life

Source: “United Nation” by ClkerFreeVectorImages, licensed CC0 Public Domain.

HOW IS THE WHO ICF RELEVANT TO ETHICS AND HUMAN RIGHTS?

�"Health is a state of complete physical , mental and social well-being and not merely the absence of disease or infirmity“ (WHO, 2006, p.1)

�"The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition" (WHO, 2006, p. 1)

Source: “Right” by geralt, licensed CC0 Public Domain.

WHO 1980 (ICIDH)� Impairment �Disability �HandicapWHO 1999 (ICIDH-2)� Impairment�Activity limitation�Participation restriction

WHO 2001 (ICF)�Part 1: Functioning and

disability� Body structure and function� Anatomical parts� Physiological and psychological

aspects� Activity and participation� Performance � Capacity

�Part 2: Contextual factors� Personal factors� Environmental factors

BOX 5–1. SUMMARY OF WHO MODELS

HOW IS THE WHO ICF SPECIFICALLY RELEVANT TO INTERVENTION AND RESEARCH IN REHABILITATION? � The ICF helps rehabilitation professionals and scholars to

oFocus on health, well-being, and quality of lifeoAcknowledge that every human being can experience a decrement in health and thereby

experience some degree of disabilityoRecognize health and disability as universal human experiencesoTake into account the dynamic interaction among � Life-impacting variables (social support, environment, genetics)� Health r isks in all aspects of assessment, treatment, and clinical research

oConsider disability not as an attribute of any given person but as a construct that can only be considered in an individual's life context, especially his or her social environment

oDeemphasize an individual's health status according to medical diagnostic categories, focusing instead on their holistic functional concerns and what might be done to address them

oAddress intervention through interdisciplinary approaches, combining the best areas of expertise to address an individual's needs

HOW IS THE WHO ICF SPECIFICALLY RELEVANT ADULTS WITH NEUROGENIC CHALLENGES?

� It represents an important departure from the traditional classification of disorders based on neuroanatomical models (impairment-based models)

� The focus is on o Any communication disorder as a contextualized life-affecting condition o Resources and compensatory and adaptive services for full life participationo Working on deficits at the level of body structure and function, but with an

eye toward impacting activity limitations through such work

�Embracing the ICF framework impacts both assessment and treatment o Aphasiologists address all aspects of communication that could affect an

individual’s life and that of others (family members, friends, etc.)


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WHAT A RE KEY THEORIES A BOUT AGING THAT A RE ESPECIALLY RELEVANT TO COGNITION A ND COMMUNICATION?

� The life-span model of postformal cognitive development (Schaie, 2005; Schaie & Willis, 2002)o 7 stageso Adulthood – taking on responsibilitieso Focus on self and family Æ focus on community and societyo Focus on professional development Æ non-professional activitieso Last 2 stages: greater selectivity in activities and emphasis on

legacies

How is this relevant to consideration of age-related changes in communication abilities and needs?

WHAT A RE KEY THEORIES A BOUT AGING THAT A RE ESPECIALLY RELEVANT TO COGNITION A ND COMMUNICATION?

� Motivational theory of life-span development (Heckhausen, Wrosch, & Schulz’s, 2010)o Self-regulatory skills9Anticipate emergent opportunities for goal pursuit9Activate behavioral and motivational strategies of goal

engagement9Disengage from unimportant goals

How is this relevant to consideration of age-related changes in communication abilities and needs?

�Helping a family member consider prognosis for recovery from an acquired language disorder due to stroke or brain injury? �Responding constructively to colleagues who make

misguided statements about the influence of age on an older person’s language abilities? �Working with a social worker on discharge planning at

a subacute rehabilitation facility?

HOW MIGHT MODELS OF AGING THAT PROMOTE CONCEPTUALIZATION OF AGING FROM A LIFE SPAN PERSPECTIVE INFLUENCE YOUR ROLE IN: WHAT ARE SOME IMPORTANT DEMOGRAPHIC SHIFTS IN THE WORLD’S

AGING POPULATION?

�The aging population is rising globally (faster in in developing countries) due to three primary reasons o Decreasing infant

mortalityo Decreasing fertility o Improved longevityo (Also, in the US,

migration)�BBC�Global Aging

Source: “Percentage of the World Population Over 65” by Rcragun, licensed under CC BY 3.0.

US POPULATION OUTLOOK US TRENDS IN PEOPLE AGE 65 AND OVER

U.S. population 65+� 2011: 13.3% (tripled in 100 years)� 2030: 1/5 of the US (doubling in 25 years)� 2050: 83.7 million� Female > male (80% of centenarians)� Increasing racial/ethnic diversity� East Coast > West Coast� Continued chronic conditions� Staying in workforce longer� Increasing educational level� Increasing use of technology


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POPULATION AGINGHOW ARE DEMOGRAPHIC SHIFTS IN AGING POPULATIONS RELEVANT (OR

POTENTIALLY RELEVANT) TO YOUR OWN PERSONAL AND PROFESSIONAL MISSION?

�Why is it so important for us to know about communication disorders among older people?

�What’s so important about communication in the context of aging… in your family, in your community, in your state, in your country, in the world?

HOW ARE THESE TOPICS RELEVANT TO YOU? What are normal changes in the brain as people age?

y General patterns of neuro-structural changes (with great variability) that have effects on cognitiono Neuron shrinkage and reduced dendritic branching

� Leads to decreased brain volumeo Atrophy primarily in the frontal lobes and hippocampus o Reduction in neurotransmitters (e.g., acetylcholine and dopamine)o Decreased white matter, especially on the frontal lobeso Reduced cerebral blood flowo Accumulation of amyloid beta or amyloid plaques without accompanying neurofibrillary

tangles (associated with Alzheimer's disease)

{As we age, our likelihood of acquiring cognitive and language disorders increases.

Neuronal shrinkage and reduced dendritic branching (leading to decreased brain volume)

Macaque study: http://www.nyas.org/publications/ebriefings/Detail.aspx?cid=37cd8b29-2037-4c42-bc96-c2370a7a799e

https://www.google.com/search?q=brain+atrophy+aging&rlz=1C1GPCK_enUS535US536&espv=2&biw=1280&bih=918&source=lnms&tbm=isch&sa=X&ved=0ahUKEwiluvSsh5zPAhUo2IMKHUzQDs4Q_AUIBygC#tbm=isch&q=neuron+dendrite

Atrophy, primarily in the frontal lobes and hippocampus

Hallowell, B. (2017). Aphasia and other acquired neurogenic language disorders: A guide for clinical excellence. San Diego, CA: Plural Publishing. ISBN13: 978-1-59756-477-9

https://www.philrichardsperformance.co.uk/blog/change-your-brain-change-your-thoughts-change-your-life-overcoming-depression-part-1/


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Reduction in neurotransmitters (e.g., acetylcholine and dopamine)

https://www.google.com/search?q=neurotransmitters&biw=1280&bih=918&espv=2&source=lnms&tbm=isch&sa=X&ved=0ahUKEwjKuJDphJzPAhXkzIMKHZW_DmYQ_AUIBigB#imgrc=Hx3TQviKTvB7JM%3A

Decreased white matter, especially on the frontal lobes

/

http://www.wisegeek.com/what-causes-a-loss-of-myelin.htm

Decreased white matter, especially on the frontal lobes

http://neurosciencenews.com/neuroplasticity-aging-learning-1557/

Reduced cerebral blood flow


http://www.daviddarling.info/encyclopedia/T/transient_ischemic_attack.html

Accumulation of amyloid beta or amyloid plaques without accompanying neurofibrillary tangles (associated with Alzheimer's disease)

http://www.brightfocus.org/alzheimers/infographic/amyloid-plaques-and-neurofibrillary-tangles

http://thecandidazone.com/candida-and-alzheimers/

Video: Plaques and Tangles in the Alzheimer's Brain

Video: Plaques and Tangles

What are positive aspects of the aging brain?


y Memory-related (semantic, procedural, and episodic) changeso Richness of life experience

y Age-related changes in prefrontal and limbic interaction, along with hormonal changes in the braino Balance of basic drives associated with sexual pursuits, career ambition, greed,

and self-centeredness

y Changes to grey and white matter pathways as well as synaptic connections o Wisdom


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Discussion: Positive aspects of the aging brain

y Do you have experience with an older person that reinforces the positive aspects of age-related changes in cognitive-linguistic development? If so, share stories of such experiences, tying them to our focus today.

Table 9–1. General Guidelines for Considering Whether Cognitive-Linguistic Characteristics of Older Adults Are Normal

May Be Associated With Normal Aging

Not Characteristic of Normal Aging

Distractibility, sometimes considered absent-mindedness

Forgetting essential information related to activities of daily living

Note that several of the characteristics in the left column may be lifelong characteristics, not necessarily characteristics that have developed in older age. Recall, too, that there is tremendous inter-and intraindividual variability in these characteristics.




Word-finding problems, especially increasing tip-of-the-tongue experiences (knowing that one knows the word and perhaps knows something about the word but is not able to actually say the word)

Semantic confusion at the discourse level





Occasional trouble finding proper names

Dysnomia for important names





Occasional math errors Dyscalculia or problems with basic mathematical functions





Normal or near-normal syntactic production (speaking and writing), with greater difficulty in distracting conditions; possible reduced use of complex grammatical forms and reduced length of sentences

Major changes in syntactic structures that were used in younger years



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Normal or near-normal syntactic comprehension (auditory and reading); greater difficulty with longer and more complex stimuli and in dual-task and distracting conditions

Moderately or severely impaired comprehension





Normal or mildly impaired working memory; greater difficulty with longer and more complex stimuli and in dual-task and distracting conditions

Moderately or severely impaired working memory





Normal or mildly decreased speed of processing during cognitive and motor tasks; greater difficulty with longer and more complex stimuli and in dual-task and distracting conditions

Moderately or severely slowed speed of processing





Normal or mildly impaired episodic memory (recall of personal experiences)

Moderately or severely impaired episodic memory





Normal procedural memory (recall for how to accomplish specific tasks)

Impaired procedural memory





Normal or mildly impaired procedural learning

Impaired procedural learning



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Normal or mildly impaired source memory (memory of where and how one acquired knowledge or where and when a previous event took place)

Impaired source memory





Normal short-term memory (recall of recent events)

Impaired short-term memory





Normal autobiographical memory (memory about important aspects of one’s past)

Impaired autobiographical memory





Near or near-normal pragmatic and executive function abilities

Impaired pragmatic abilities and executive function deficits


What tends to be well preserved in older adulthood?


y Memoryo Semantic memoryo Procedural memoryo Autobiographical memory

(Episodic, source, and short-term memory also commonly spared)

y Word findingo Good recognition; not a matter of loss of

vocabulary

y Syntactic processing o Facilitation through slowing and reduced

background noise/clutter

y Reading and writingo Linguistic aspects relatively spared

y Discourseo Good understanding for narratives

(stories)o Production judged to be clearer and

more interesting (Glisky, 2007; Kemper & Kemtes, 2000)

y Pragmaticso Aging in and of itself does not seem to

influence pragmatic abilities in significant ways. (Consider lifespan models and motivational theory of development.)

What are normal changes in cognition and language as people age?


y Memoryo Short-term and working memory

y Word findingo More “tip-of-the-tongue” experienceso Slower response times o Less accuracy o Reduced verbal fluency

y Syntactic processing o Comprehensiono Production

y Reading and writingo More likely to be due to sensory and

motor deficits than to linguistic factors per se

y Discourseo Three influencing factors (Shadden, 2011)

� Emotional regulation� Personal discourse goals� The nature of specific discourse tasks

y Pragmaticso Aging in and of itself does not seem to

influence pragmatic abilities in significant ways


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What theories have been proposed to account for cognitive-linguistic changes with aging?

y Resource capacity theories (Burke & Shafto, 2008)

o A reduction in overall cognitive capacity� Working memory� Context processing deficiency� Signal degradation� Transmission deficit

y Speed of processing theorieso Our cognitive processing at all levels slows as we age (the general slowing

hypothesis (Salthouse, 1996)

y Inhibition theorieso Difficulty with inhibiting attention to irrelevant information externally and

internally (Butler & Zacks, 2006; Hasher & Zacks, 1988; Zacks & Hasher, 1993)

Queries for group processing

y What is reserve capacity (or cognitive reserve)? Why is it important for people to know about it?

y What is age-related identity threat? Why is it important to take it into account when assessing communicative abilities of older people?

y Why is it that physical changes that might be detected in the brains of older people do not necessarily correspond to problems in their functional cognitive and linguistic abilities?

y What can be done to ensure the best preservation of language abilities as people age?

Box 9–1. Factors That Promote Brain Health Through the Life Span How are you doing?

1. Active intellectual engagement on a daily basis2. Regular active and pleasurable social engagement and support3. Limitation of time spent in passive activities, such as watching television4. Constructive and proactive management of low mood, stress, and anger 5. Cardiovascular fitness, including well-regulated blood pressure6. Maintenance of low body fat7. Sufficient rest8. A well-balanced diet with well-controlled glucose regulation9. Alcohol consumption only in moderation if at all10. When possible, avoidance of drug effects and pharmacological interactions

that negatively affect brain and language functions

Language in the Context of Aging:Clinical Advocacy for Older Adults

Brooke Hallowell



Assumptions, stereotypes, and attitudes that affect services for older people



Challenging research on the ravages of agingWhy is it important to scrutinize carefully and not necessarily accept as fact the results of research studies that demonstrate declines in cognitive and linguistic abilities as people age?


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Challenging research on the ravages of agingConsider these influences on research: • Heterogeneity of the “older” population• Demographic aspects of the samples studied• Control for potentially confounding factors• Longitudinal research challenges• Cohort/cross-sectional research challenges

• conditions related to a group of people having lived through similar circumstances or points in time

What is elderspeak?



• Is elderspeak helpful or is it discriminatory? • Group role play

• What are some positive modifications that can be used instead of elderspeak?

Discussion



• Symptoms of dementia have been assumed by many to be patterns of normal aging. What examples of such assumptions have you heard about or witnessed? How can such assumptions lead to negative consequences for older people?

• What are specific ways in which negative attitudes toward aging may affect health care for older people?

• What may be your role in:• Helping a family member consider prognosis for recovery from an acquired language

disorder due to stroke or brain injury?• Responding constructively to colleagues who make misguided statements about the

influence of age on an older person’s language abilities?• Working with a social worker on discharge planning at a subacute rehabilitation facility?

• How will you continue to challenge your own stereotypes about aging that may negatively affect your role in supporting older adults?

Countering impairment foci and medicalization



Green house project

• http://www.thegreenhouseproject.org/

• Check out news stories:• http://www.thegreenhouseproject.org/news/Media-Coverage

Person-Centered Care

• Person-centered care matters, Center for Positive Aging


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Program for positive aging

• http://www.programforpositiveaging.org/

Center for positive aging

• https://www.centerforpositiveaging.org/

Center for the future of aging

• Milken Institute: http://www.milkeninstitute.org/centers/the-center-for-the-future-of-aging/

Second acts for the greater good

• http://encore.org/

The National Center for Creative Aging is dedicated to fostering

an understanding of the vital relationship between creative

expression and healthy aging and to developing programs that

build upon this understanding.

Envision a world where all individuals flourish across their lifespan through creative expression…

CreativeAging.orgWinners of the 2014 Beautiful Minds Campaign presented by NCCA and DSM Nutritional Products


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Positive EmotionPositive EngagementPositive RelationshipsMaking of MeaningMastery

Gene Cohen, The Creative Age

Martin Seligman, Flourish

Longevity, Creativity, Flourishing Evidence-Based Impact� Vital evidence-based efficacy and positive impact of creative arts and

humanities interventions with aging populations

� Improved health, higher quality of care, resilience,

and quality of life across the spectrum of aging

� Effective for aging adults AND their caregivers by

mitigating long-term depression and anxiety related to

chronic conditions, and enhancing quality of life

� Reducing social and healthcare costs, enhancing

professional provider resilience, and

strengthening networks of care.

The Heart of the Matter� Creating Quality days

for both caregiver and care partner� Living at home for as

long as possible� Strengthening family

relationships� Creating meaning,

memory, and legacy

Documents

Why are we here? 2017 Hallowell... · Strengths-Based Perspectives Brooke Hallowell Hallowell, B. (2017). ... An important approach led by the WHO to classify functional areas of