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REHABILITATION OF COMMUNICATIVE-PRAGMATIC ABILITY AND AGING Parola, Alberto; Bosco, Francesca M.
The ability to communicate effectively in a social context may decrease as a consequence of the normal process of ageing, and may be caused by physiological and neurological changes as well as changes in the personal environment, which usually characterise old age. Older adults frequently show a generalised cognitive decline (Glisky, 2007), caused by a reduction in the cortical connectivity of the frontal lobe (Hess, 2005), which primarily affects high-order cognitive functions such as executive functions, i.e. planning, working memory and inhibition, and is accompanied by an alteration in hearing and speech processes. These modifications may affect the ability to use language, resulting in difficulty with name retrieval and recalling, circumlocution, reduction of the syntactic complexity of sentences, and prosodic alterations, which may be accompanied by a defective emotion recognition (Burdon, Dipper & Cocks 2016). In addition to a possible generalised cognitive decline during the normal process of ageing, the onset of many neurological disorders is in late adulthood; the most prevalent diseases that often impair communicative ability in old age are stroke, traumatic brain injury, dementia (in particular, Alzheimer disease), and Parkinson’s disease. Individuals with Parkinson’s disease present prosodic difficulties, such as reduced speech stress, monotonic pitch and inappropriate pauses, as well as a reduction of the informative contents in the discourse, and pragmatic deficits (Berg et al., 2003). Individuals with dementia report deficit in word retrieval, circumlocution, production of irrelevant utterances, lack of coherence and rapidly shifting topics (Bayles et al., 2000). Communicative disorders in people with brain damage are heterogeneous, and vary according with the size and origin (vascular or traumatic) of the lesion, but the most prevalent disturbances include aphasic symptoms, difficulties in modulation and recognition of the tone of voice, verbosity, tangentiality, social inappropriateness, pragmatic and inferential deficits, especially in understanding the most complex forms of language (irony, metaphor, idioms) and narrative disorders (Orange, 2009; Bosco et al., 2015; Parola et al., 2016).
In normal ageing the psychosocial consequences of communicative difficulties in daily activities may be serious. Older adults often experience a reduction in social contacts, and communicative difficulties can further weaken their social network. In addition, older adults frequently need of assistance services, and “the ability to communicate successfully, including speaking, listening, reading, and writing, is a critical factor in obtaining health care” (Yorkston, Bourgeois & Baylor, 2010, p. 5). In patients, communicative disorders are an obstacle to a full recovery from injury and the return to previous daily activities. Language and communicative rehabilitation is thus extremely important in order to limit the social consequences of communicative disorders in old age. The benefits of the approaches aimed to assess and enhance communicative ability are not limited to patients, but could be extended to adults that are experiencing communicative difficulties connected with the normal process of ageing.
We will now focus on the rehabilitation of communicative disorders in older people with brain damage (BD). The first aim of communicative rehabilitation is to identify the specific profile of communicative impairment, in order to provide a rehabilitative programme focused on the patient’s difficulty. Traditionally, rehabilitative approaches have focused on the recovery of linguistic ability, but recovery in linguistic function does not necessarily correspond to an effective improvement in the ability to communicate in a real-life context. Moreover, patients with BD exhibit frequent deficits that also affect non-verbal, i.e. gestural, modality, which the majority of treatments specifically focused on language often neglect (Angeleri et al., 2008). To overcome these limits some authors have proposed the pragmatic approach, such as the Functional Communication Treatment (Aten, Caligiuri & Holland, 1982), where aphasic patients were trained to implement non-verbal strategies to solve everyday communicative tasks, or the Promoting Aphasics Communicative Effectiveness (Davis & Wilcox, 1985), in which an examiner requires patients to describe a card, with the help of the therapist, that gives him feedback and suggests compensatory strategies in order to improve the efficacy of his communicative performance. A distinctive feature of the pragmatic approach is the presence of the group, which recreates the cognitive demands set by a real-life communicative setting, such as rapid and overlapping turn-taking, and promoting generalisation of the skills acquired in the training. The group also favours the creation of new social relationships, extending the social and supportive network of the participants.
Patients with BD often also show behavioural disturbances, referred to as ‘personality changes’ and attributable to brain damage, that limits communicative skills, making them over-talkative, socially inappropriate, aggressive and perseverative. To overcome difficulties in communication, social skills training has also been proposed (e.g., Ylvisaker, Turkstra & Coelho, 2005). This training includes a wide range of techniques such as modelling, role play, feedback, self monitoring, group discussion, with the aim to foster pro-social and adaptive communicative behaviour. The role played by the patient’s caregiver(s) is another important aspect of communicative rehabilitation. The therapist provides useful advice to the patient’s caregiver(s), helping them to know the cause and to manage the consequences of the disorders, and suggesting how to reinforce the compensatory strategies proposed during rehabilitation.
Other important issues, such as the level of awareness of the deficits and the general cognitive profile of the patients, have to be addressed in rehabilitation with older adults with BD. Indeed, the cognitive decline, as in executive functioning and theory of mind, i.e. the ability to attribute mental states to oneself and to other people, or a scarce awareness of these deficits, could dramatically limit the treatment efficacy. Recently, Gabbatore et al. (2015) proposed the Cognitive Pragmatic Treatment (CPT), an articulated training programme created to improve patients with BD communicative ability. The CPT consists of 24 group rehabilitation sessions, each focused on a different aspect of communication. The treatment takes into account the linguistic, non-verbal and paralinguistic expressive means, encouraging patients to use all the communicative modalities and preserved abilities to reach the communicative goals set by a specific task. The techniques used in the training include role plays, the viewing of video clips that represent communicative exchange followed by group discussion, and exercises with audio and printed materials. The CPT has proved its efficacy in a sample of patients with traumatic brain injuries, and reported a better communicative performance that was stable after 3 months by the end of the treatment (Gabbatore et al., 2015).
Also, adults with normal ageing can benefit from rehabilitative approaches aimed to improve and enhance communicative skills, which could help them to prevent cognitive decline and preserve communicative ability. Another key aspect of communicative rehabilitation is the maintenance and reinforcement of the social and support network that can positively reflect on the quality of life. However, some critical issues should be considered
when older adults are included in rehabilitative treatment: the rhythm and the time of the activity should be carefully tailored to the needs of older adults. Cognitive decline and physical fatigue can indeed reduce their attention and their responsiveness during the treatment, and role of the experimenter is to constantly monitor and prevent possible treatment withdrawal.
Reference
Angeleri, R., Bosco, F. M., Zettin, M., Sacco, K., Colle, L., & Bara, B. G. (2008). Communicative impairment in traumatic brain injury: A complete pragmatic assessment. Brain and Language,
107(3), 229-245.
Aten, J. L., Caligiuri, M. P., & Holland, A. L. (1982). The efficacy of functional communication therapy for chronic aphasic patients. Journal of Speech and Hearing Disorders, 47(1), 93-96. Bayles, K. A., Tomoeda, C. K., Cruz, R. F., & Mahendra, N. (2000). Communication abilities of individuals with late-stage Alzheimer disease. Alzheimer Disease & Associated Disorders, 14(3), 176-181.
Berg, E., Björnram, C., Hartelius, L., Laakso, K., & Johnels, B. O. (2003). High-level language difficulties in Parkinson's disease. Clinical linguistics & phonetics, 17(1), 63-80.
Burdon, P., Dipper, L., & Cocks, N. (2016). Exploration of older and younger British adults’ performance on The Awareness of Social Inference Test (TASIT). International Journal of
Language & Communication Disorders.
Bosco, F. M., Angeleri, R., Sacco, K., & Bara, B. G. (2015). Explaining pragmatic performance in traumatic brain injury: a process perspective on communicative errors. International Journal of
Language & Communication Disorders, 50(1), 63-83.
Carlomagno, S., Blasi, V., Labruna, L., & Santoro, A. (2000). The role of communication models in assessment and therapy of language disorders in aphasic adults. Neuropsychological
rehabilitation, 10(3), 337-363.
Davis, G. A., & Wilcox, M. J. (1985). Adult aphasia rehabilitation: Applied pragmatics. College-Hill Press.
Gabbatore, I., Sacco, K., Angeleri, R., Zettin, M., Bara, B. G., & Bosco, F. M. (2015). Cognitive pragmatic treatment: a rehabilitative program for traumatic brain injury individuals. The
Journal of head trauma rehabilitation, 30(5), E14-E28.
Glisky, E. L. (2007). Changes in cognitive function in human aging. Brain aging: models,
methods, and mechanisms, 3-20.
Hess, T. M. (2005). Memory and aging in context. Psychological bulletin, 131(3), 383. Orange, J. B. (2009). Language and communication disorders in older adults: selected considerations for clinical audiology. Hearing Care for Adults, 87-102.
Parola, A., Gabbatore, I., Bosco, F. M., Cossa, F. M., Gindri, P., & Sacco, K. Linguistic,
extralinguistic and paralinguistic abilities in patients with right hemisphere damage (RHD). Yorkston, K. M., Bourgeois, M. S., & Baylor, C. R. (2010). Communication and aging. Physical
medicine and rehabilitation clinics of North America, 21(2), 309-319
Ylvisaker, M., Turkstra, L. S., & Coelho, C. (2005). Behavioral and social interventions for
individuals with traumatic brain injury: A summary of the research with clinical implications. In
