My Gray is Golden: Thoughts About Aging From the Perspective of Adults With Neurologically Based Communication Impairments Aging with disability may follow several trajectories, depending on the nature of the disability, the age of onset, the individual differences in the person, and the support systems available. This article will discuss theories of aging and loss together with various neurological diagnoses, where the two conditions (aging and neurological ... Article
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Article  |   January 01, 2014
My Gray is Golden: Thoughts About Aging From the Perspective of Adults With Neurologically Based Communication Impairments
Author Affiliations & Notes
  • Gloriajean L. Wallace
    Dept. Communication Sciences and Disorders, College of Allied Health Sciences, University of Cincinnati, Cincinnati, Ohio
  • Disclosure: Financial: Gloriajean L. Wallace is a Professor Emerita and Medical Speech-Language Pathologist at the University of Cincinnati.
    Disclosure: Financial: Gloriajean L. Wallace is a Professor Emerita and Medical Speech-Language Pathologist at the University of Cincinnati.×
    Nonfinancial: Gloriajean L. Wallace has previously published in this subject area. Some of her works are referenced in the piece.
    Nonfinancial: Gloriajean L. Wallace has previously published in this subject area. Some of her works are referenced in the piece.×
Article Information
Special Populations / Older Adults & Aging / Language Disorders / Articles
Article   |   January 01, 2014
My Gray is Golden: Thoughts About Aging From the Perspective of Adults With Neurologically Based Communication Impairments
SIG 15 Perspectives on Gerontology, January 2014, Vol. 19, 24-35. doi:10.1044/gero19.1.24
SIG 15 Perspectives on Gerontology, January 2014, Vol. 19, 24-35. doi:10.1044/gero19.1.24

Aging with disability may follow several trajectories, depending on the nature of the disability, the age of onset, the individual differences in the person, and the support systems available. This article will discuss theories of aging and loss together with various neurological diagnoses, where the two conditions (aging and neurological condition) lead to individual differences in coping, compensation, and outcome.

Speech-language pathologists provide habilitation and rehabilitation services for individuals who range in age from infants to elders and who represent a diverse spectrum of communication disorders. When doing so, we place emphasis on providing the best clinical care for the person and family using a blend of resources, including evidence-based practice, case and family input, clinical experience, and colleague consultation. Much of the speech-language assessment and treatment of infant, pediatric, school-age, and adolescent populations is directed by developmentally based guidelines. Examples of this can be found in the area of pediatric dysphagia (Prasse & Kikano, 2009; Rowe, 1999), phonology (Schmitt & Justice, 2012; Stoel-Gammon & Williams, 2013), language (Fujiki, Brinton, McCleave, Anderson, & Chamberlain, 2013; Park & Lombardino, 2013) and voice/fluency (Baker & Blackwell, 2004). Developmental considerations are, in fact, at the core of speech-language management for young clinical populations. Consideration of developmental issues seems not to be as systematically addressed as a part of the clinical care package for older clinical populations. This is perhaps because developmental changes among the elderly are not as striking and not as well known or understood; especially in instances when multiple unexpected life changes occur within a relatively short span of time. Another likely reason is the paucity of information describing how changes with advanced age confound and complicate disabilities associated with communication disorders experienced later in life.
Ages and Stages: Theories about Aging
There are numerous theories about changes that occur across the lifespan for older persons. In order to provide perspective about what is involved with the aging process, four theories about aging will be reviewed.
Disengagement Theory
The Disengagement Theory, developed by Cummings and Henry (1961), is one of the earliest and most controversial theories of aging. The Disengagement Theory views aging as a process of gradual withdrawal between society and the older adult. Mutual withdrawal or disengagement is presumed to be a natural, acceptable, and universal process applicable to elders across cultures. With this system, gradual withdrawal from society and relationships is thought to preserve social equilibrium and promote self-reflection for elders who are freed from societal roles. This system provides an orderly means of transferring knowledge, capital, and power from the older generation to the young. It also makes it possible for society to continue functioning after valuable older members have died. A weakness of this theory is that many elders desire to remain active in their communities. The World Health Organization's International Classification of Functioning, Disability and Health Model (ICF; World Health Organization, 2001) and the Life Participation Model (Chapey et al., 2000) would suggest that it is not socially or psychologically acceptable for elders to withdraw from society. This theory has been largely discounted by gerontologists.
Activity Theory
According to the Activity Theory, developed by Havighurst (1961), older persons should remain physically and intellectually active throughout their lifetime. The Activity Theory is diametrically opposed to the Disengagement Theory. Activity refers to full engagement in the sense of continual development of new interests, hobbies, roles, and relationships that replace ones that have been reduced or lost late in life (for example, due to retirement). According to this theory, society should not encourage diminished societal involvement by older persons. A weakness of this theory is that it is not supportive of individuals who are unable to maintain a middle-aged lifestyle because of functional limitations, reduced income, or lack of desire to do so. To the contrary, this theory places pressure on the elder to maintain an active lifestyle. For this reason, some elders might insist on engaging in activities that are unsafe in order to fulfill their self-perceived role as an active and independent member of society (for example, driving at night despite low visual acuity).
Continuity Theory
The Continuity Theory, developed by Atchley (1971), builds upon and modifies the Activity Theory (Havighurst, 1961). This theory promotes the notion that an individual's personality, values, morals, preferences and role in life are consistent over the entire life span. The Continuity Theory assumes that life as an older person is simply a continuation of the earlier part of the person's life. According to this theory, interests and activities pursued as a young person will be continued as an older person (with modifications as needed).
The Wonder of Aging Theory
The Wonder of Aging Theory is a new, biological-psychological-spiritual theory (Gurian, 2013). According to this theory, healthy aging is based on four core elements: de-stressing; an optimistic perspective about aging; membership in supportive community groups; and developing avenues for self-growth. There are three stages involved with this theory. Stage 1 is the Age of Transformation (50–65 years of age). During Stage 1, the person experiences menopause, andropause, and physical and spiritual changes as they move into the second half of life. Stage 2 is the Age of Distinction (65–late 70s). During Stage 2, there is a sense of pride in what has been created, nurtured, and experienced over the lifetime. Regardless of marital status (single, widowed, divorced, or remarried), there is generally a sense of autonomy; an ability to face life with internal strength and capability. By this stage, people have generally found themselves and are able to look back on work and family life with joy. Stage 3 is the Age of Completion (80–100 +). This stage is a deeply spiritual period when the person begins to downsize and detach in preparation for completion of the journey before passage.
Contributions From Geriatrics and Gerontology About Lifespan Changes
There is a vast wealth of knowledge from geriatrics and gerontology about changes that occur across the lifespan. Geriatrics is a branch of medicine that specializes in diseases of older adults (Webster's New World College Dictionary, 2008). As members of American Speech-Language-Hearing Association Special Interest Group (SIG) 15, Gerontology, we are part of a network of professionals who serve people of advancing age. The term gerontology refers to the study of social, psychological, and biological aspects of aging. In addition to speech-language pathologists, gerontologists include other researchers and practitioners from professions such as audiology, physical therapy, and occupational therapy; psychology, psychiatry, sociology, nursing, dentistry, pharmacy, optometry, public health and other medical areas; political science, economics, architecture, housing, geography, urban planning, and public health.
This multidisciplinary area, gerontology, is divided into four broad sections: chronological aging, biological aging, psychological aging, and social aging. Chronological aging is defined as years lived from birth. Biological aging refers to physical changes that reduce the efficiency of organ systems. Psychological aging relates to changes that occur in sensory and perceptual processes, cognitive abilities, adaptive capacity, and personality. Social aging details changes in roles and relationships with family and friends, including matters relating to life participation (Chapey et al., 2000).
Because the American Speech-Language-Hearing Association (ASHA) recognizes the importance of aging issues and their relevance to the provision of quality care, ASHA Special Interest Group 15 (SIG 15) has joined with the Gerontology Society to form the Partnership for Health in Aging (PHA). The PHA is a multidisciplinary coalition of organizations formed to advocate best practices when providing services to older persons. This group promotes dissemination of knowledge about relevant developmental, cultural and other pertinent information affecting assessment, treatment and team participation during the implementation of care for geriatric cases and their family members (American Geriatrics Society, 2013). To read more about the PHA multidisciplinary competencies associated with caring for older adults, the PHA position statement on interdisciplinary team management (supported by ASHA), and other information relating to the PHA, the reader is directed to the American Geriatrics Society website (2013). Through the areas of geriatrics and gerontology, there is a wealth of knowledge about the significant physical, neurological, social, and psychological changes that may occur throughout the lifespan (Cavanaugh & Blanchard-Fields, 2011). These include the change or risk for change in skin and hair (affecting appearance and self-image); teeth (affecting appetite and eating); voice quality and hearing acuity (affecting communication); bone structure, balance, strength, mobility, energy level, and use of upper extremities (e.g., arthritic changes affecting activities of daily living); vision (e.g., due to risks associated with presbyopia, glaucoma and cataracts; affecting sight and ability to read); taste and smell; cardiovascular, cerebrovascular, and respiratory functioning; memory; reproductive system (e.g., female menopause and male andropause and prostate); limbic system (depression associated with social isolation that may occur with advanced age and other causes of depression). Most people of advanced age have some health related comorbidity with resulting disability (Young, Frick, & Phelan, 2009).
Interestingly enough, the stem “ger-” in the word “geriatric” is a Greek derivative, meaning “to grow ripe” (Webster's New World College Dictionary, 2008). This brings to mind positive images, such as fruit becoming sweeter as it ripens with time. However, for some, the above described changes are perceived to be losses.
Kübler-Ross Five Stages of Grief Model
Because changes that occur with advanced age are viewed by some as losses, we have included a description of the Kübler-Ross Five Stages of Grief Model (Kübler-Ross, 2005). The Kübler-Ross Stages of Grief Model was originally developed from her observations of people suffering from terminal illness (Kübler-Ross, 1969). Kübler-Ross later expanded and applied her theory to other forms of personal loss.
The Kübler-Ross Five Stages of Grief include:
  1. Denial – “I am ok. This is not really happening to me.” Typically a temporary defense. A conscious or unconscious refusal to accept facts or the reality of the situation.

  2. Anger — “This is not fair! Why me? Who is to blame?” The person is no longer denying reality in this stage of anger.

  3. Bargaining — “I'll do anything to make this situation go away.” This stage involves clinging to hope that the person can postpone or negate the reality of the situation.

  4. Depression — “I feel badly about the situation. Why go on?”rdquo; During this stage, the person becomes very depressed—demonstrating that they are beginning to accept the reality of the situation.

  5. Acceptance — “It will be alright.” In this stage the person comes to terms with what has happened.

Demographics
People 65 Years and Older
Speech-language pathologists providing services to people age 65 and older can expect their caseloads to increase over time. According to the 2010 census data, the U.S. population of citizens 65 and older is now the largest ever, in terms of size and percent of population as compared with previous census records The census also shows that the 65 and older population is growing faster than the total U.S. population, when growth patterns are examined over the period from 2000 (35 million) to 2010 (40.3 million; Administration on Aging, Administration for Community Living, Department of Health and Human Services, 2012; Federal Interagency Forum on Aging-Related Statistics, 2000). This represents an increase of 5.3 million people over the 10-year period. By 2050, the number of U.S. citizens 65 and older is projected to be 88.5 million; more than double the comparable 2010 population of 40.3 million (Vincent & Velkoff, 2010).
Vincent and Velkoff (2010)  predict that numbers will drastically increase from 2010 to 2050 for individuals in the five major racial/ethnic groups age 65 years and older. This includes an increase from 8.6% to 18.5% for African Americans, from 5.7% to 13.2% for Latino Americans, from 9.3% to 21.9% for Asian Americans, from 7.4% to 16.8% for Native Americans/Alaskan Natives, and from 6.5% to 17.9% for Native Hawaiians/Pacific Islanders. For this reason, it will be important for speech-language pathologists working with the geriatric population to be sensitive and well versed about issues pertaining to diversity (Payne, 1997; Wallace, 1997).
General Communication Disorders Among the Elderly
In a large survey of Medicare beneficiaries age 65 years and above, Hoffman, Yorkston, Shumway-Cook, Ciol, & Dudgeon (2005)  explored the general communication status of over 12,000 Medicare beneficiaries. In this general sample, 42% of the respondents reported having a hearing problem, 26% had writing problems, and 7% had problems using the telephone. When statistical procedures (sampling weights) were used to make inferences about the total Medicare population, the researchers reported over 16 million Medicare beneficiaries were estimated to have communication changes (Yorkston, Bourgeois, & Baylor, 2010).
Adult Onset Neurogenic Communication Disorders
It is also of interest to note that as people advance in age, they are at risk for specific adult-onset medical conditions and injuries that increase the likelihood of a communication disorder. There are two trajectories for these disorders (Yorkston et al., 2010): Disabilities that occur with aging that affect people who have lived most of their lives without disability until they experience either a communication problem associated with age (e.g., hearing loss) or an acquired neurogenic communication disorder (e.g., stroke, aphasia, TBI, Alzheimer's disease, and Parkinson's disease). There are other disabilities that typically begin before old age (e.g., Multiple Sclerosis, Primary Progressive Aphasia, Amyotrophic Sclerosis, and Huntington's Chorea). In this later group, the person ages in the context of an already existing disability. A synopsis of major neurogenic communication disorders and neurologically based medical conditions resulting in communication disorders that affect adults across the lifespan, with statistics, is provided below.
Aphasia. Aphasia is a communication impairment that affects speaking, verbal expression, reading, and writing and that masks communicative competence (National Aphasia Association, 2013a). This “silent disability” (Sarno, 1986) affects 1 million people in the United States (National Institute of Neurological Disorders and Stroke [NINDS], 2013a). The major risk factor for aphasia is stroke, which increases with advancing age. Stroke affects 15% of individuals under the age of 65 years and rises to 43% for individuals 85 years of age and older (Engelter et al., 2006). Current medical literature highlights that stroke is becoming an increasing medical problem among young adults (Kissela et al., 2012; Sultan & Elkind, 2013) that will impact the number of cases with aphasia and other stroke-related disabilities in the future. Less common causes of aphasia include traumatic brain injury, brain tumor, and infections (National Aphasia Association, 2013a).
Traumatic Brain Injury. TBI is a result of a blow to the head that may result in bruising of the brain, tearing of nerve fibers, and bleeding (Brain Injury Association of America, 2013; NINDS, 2013b). There are myriad causes of TBI; for example, bullets, vehicle injuries, violence, and falls. Combat- and sports-related TBI are receiving great attention, especially as information is becoming known about the devastating long-term effects of mild brain injury (mTBI). TBI results in a host of mild-to-severe cognitive-communication impairments. The constellation of deficits depends on the part of the brain affected (focal or widespread). The annual incidence of TBI among the elderly in the United States is 155,000, primarily due to falls (Mak et al., 2012). This results in a range of outcomes (mortalities and chronic disabilities, including mild traumatic brain injury-mTBI). Many elderly TBI cases are discharged to long-term care facilities where they must accept changes in cognitive status from the TBI, as well as changes in living environment and social network (Karon, Lazarus, & Holman, 2007). SLPs providing services with elders with mTBI will have to be creative during clinical planning, given that mTBI is a new area with sparse evidence-based guidance relating to the geriatric populations.
Multiple Sclerosis [MS]. MS is an inflammatory disease that damages the insulating coverings of the brain and spinal cord nerve cells. This results in disruption of the ability of nervous system communication, causing a wide range of progressive or relapsing physical, mental, psychiatric symptoms (Multiple Sclerosis Association of America, 2013; NINDS, 2013c). Speech-language pathology-related impairments include speech and cognitive communication disorders. There are 400,000 people in the United States living with MS, which generally begins in the late 20s or early 30s (Statistic Brain, 2012). MS can start as early as childhood or as late as after 50 years of age. 10% of all cases of MS are diagnosed after 50 (Statistic Brain, 2012). Individuals diagnosed with MS during early or mid-adulthood must learn to live with the MS-related disabilities as they advance with age, which, for some, might cause a disability cumulative effect over time.
Alzheimer's disease. Alzheimer's disease is caused by the abnormal formation of neurofibrillary tangles and plaques in the brain, these destroy healthy brain cells. These abnormalities settle in brain areas that control memory and the ability to learn new information (Alzheimer's Association, 2013a; NINDS, 2013d). Dementia results in the gradual deterioration of intellectual abilities and behavior that eventually interferes with day-to-day activities. Dementia effects memory, judgment, concentration, cognition, language, social interactions, visual perception, and temperament. Dementia becomes more severe as it progresses from early to middle and late stages. 5.2 million Americans have Alzheimer's disease, which typically affects people age 65 years and older (Alzheimer's Association, 2013b). 200,000 people in the United States under 65 have early onset Alzheimer's disease (Alzheimer's Association, 2013b).
Parkinson's disease. Parkinson's is a progressive disease that is caused by an insufficient production of the chemical neurotransmitter dopamine in the brain. Dopamine is important in controlling movement and in helping muscles to move smoothly. Insufficient levels of dopamine result in movement disorders affecting the body and speech (dysarthria; American Parkinson's Disease Association, 2013; NINDS, 2013e). The four major symptoms of Parkinson's disease are tremor, stiff muscles, slow movement, and problems with walking or balance. Parkinson's disease affects 1 million people in the United States, usually after the age of 65 years (Parkinson's Disease Foundation, 2013). Approximately 1% of all seniors have some form of this disease.
Primary Progressive Aphasia. Primary Progressive Aphasia (PPA) is a disorder that entails the loss of language function over time. PPA begins gradually; initially affecting the ability to retrieve words. PPA often progresses to the point that the person is unable to communicate verbally. Auditory comprehension and reading also may be affected. As the illness progresses, memory, reasoning, and visual perception are affected, with great impact on the person's ability to carry out routine activities of daily living (National Aphasia Association, 2013b; NINDS, 2013a; Northwestern University Cognitive Neurology and Alzheimer's Disease Center, 2012). There are a variety of language symptoms that can occur with PPA, resulting in variable case profiles. PPA affects less than 200,000 people in the United States. PPA typically has an onset of between 55 and 65 years of age. The average age at diagnosis is 60 years of age, according to the National Institute of Health's Office of Rare Diseases (Right Diagnosis, 2013).
Huntington's Chorea. Huntington's Chorea is an inherited disease that results in the degeneration of brain nerve cells. This disease has a broad impact on the person's functional abilities and results in a constellation of movement, cognitive, and psychiatric disorders. Difficulties include involuntary jerking or writhing movements (chorea); involuntary sustained contracture of muscles (dystonia); rigidity; slow, uncoordinated fine movements; slow or abnormal eye movements; impaired gait, posture, and balance; dysarthria and dysphagia; and cognitive disorders (Huntington's Disease Society of America, 2013; NINDS, 2013f). These potential problems make it difficult for the person to carry out activities of daily living and hamper their ability to function independently. Huntington's Chorea affects 100,000 people in the United States; usually people in their 40s and 50s (Mayo Clinic Staff, 2013).
Amyotrophic Lateral Sclerosis (ALS). ALS is a progressive neurodegenerative disease that affects nerve cells in the brain and spinal cord. People generally live 5–7 years from the time of ALS diagnosis (Amyotrophic Lateral Sclerosis Association, 2013; NINDS, 2013g). With this disease, the brain is unable to initiate and control muscle movement because of the death of motor neurons that control function. Initial signs of ALS include muscle weakness of the arms and legs, speech and swallow areas, and breathing. By the end stage of ALS, there is loss of nearly all voluntary movement and eventually paralysis. ALS affects 1,087 people in the United States; usually between the ages of 40 years and 70. The average age at time of diagnosis for ALS is 55 (Amyotrophic Lateral Sclerosis Association, 2013).
Aging and Communication Disability From a Real World Perspective
One case interview and 2 cases are presented to provide a sense of how aging might impact people with neurologically based communication impairments and their loved ones from a real world perspective. These cases are intended to generate food for thought for speech-language pathology gerontologists involved with clinical care, multidisciplinary collaboration, and research.
Case #1 and Interview: Person with Aphasia and Husband
Mrs. B is an 82-year-old Caucasian American female, 17 years post stroke. She was 65 years old at the time of the stroke. Mrs. B now has moderate-to-severe Broca's aphasia. She was formally employed as an executive at a local business. Mrs. B explained how initially after the stroke, she was unable to speak. She reports that as a result of numerous SLP treatment efforts over the years, she is now able to communicate in a manner that is satisfactory to herself and her family. These treatments have included insurance-covered, out-of-pocket, and research-related programs. In addition, she continues to engage in daily home self-practice and immerses herself in opportunities to engage in conversation with others through her participation in two weekly aphasia support groups (one that she and her husband lead), one monthly aphasia support group, a bridge club with lifelong friends, and other activities.
Mr. B (husband) is an 84-year-old Caucasian American male, who was 67 at the time of his wife's stroke. Before retirement at age 65 years, he was employed as an engineer. After retirement, he continued to work on a contractual basis until his wife's stroke. He discontinued the contractual work after that time so that he could focus on her stroke and aphasia care and recovery.
SLP: (turning to Mrs. B) Tell me about your age.
Mrs. B: Eighty two and good. Very good. Have grandchildren. 32 great…grandchildren. Between husband – me (pointing to husband and self). Both. Second marriage why have so many. (laughs)
SLP: …and the aphasia?
Mrs. B: Aphasia. Made things (pause) different. Not like…expected. Retired. Planned…travel. All over world. Bought plane ticket. We were going…go…China… Berlin. Everywhere. Then… stroke… hospital. After. Went places…but not out… country. Very different life now. Good life…but different.
SLP: So what's it like getting older with aphasia?
Mrs. B: (glancing at her husband and smiling) Aging part. (laughing) First…not talk. Hand. (pointing to her left hand). Hospital. Therapists not understand why. Not use right hand. Stroke took that one out. Left hand. Why did not want…try. Could not. Left hand hurt…so bad. Arthritis…left hand. Could not make them understand. Finally…Got it. They got it! Still…have trouble…using that hand. So…we splurge. Every Wednesday. 10:00 am. To the hairdresser I go…for my hair and nails. Every week! (smiling) Have to look…stay pretty!
SLP: (turning to Mr. B) How are things for you?
Mr. B: Well, even though she's the one with the aphasia. I'm the one in bad shape! (they both look at one another and laugh.) I have a bad hearing loss. You have probably noticed my hearing aids. I started losing my hearing about 12 years ago. I was 75 years old or so. Boy, that was a big adjustment. I finally broke down and got the hearing aids. Then my vision started getting worse. Turned out I had cataracts…so I had to have cataract surgery. Everything is ok now with my vision. I also have back problems and I am not as strong as I used to be. I can't do chores around the house like I used to. I have to call my boys to do things for me now. That used to bother me. But now it doesn't. I realize there are just some things I can't do any more. You know, we sold our house. It was only a little ranch, but we decided we couldn't take care of that any longer. So we just bought a condominium. A very small place. We are going to let the condo people take care of everything. (Couple looks at each other and laughs.) So we just have to make new friends now in this new neighborhood!
SLP: New friends with new activities to schedule now? (When asked about friends and activities, Mr. B expressed that they remain active in order to avoid “social isolation.” He said they both desire to remain a vital part of community and society—as they have been since their youth. Despite the busy lifestyle, Mr. and Mrs. B care for the affairs of Mrs. B's 99 year old mother and also manage to take her on weekly outings.) You sound like you have a joy-filled lifestyle. What makes this all work so well?
Mr. B: Well, we plan each day carefully, including our meals. We eat most of our meals in wholesome restaurants that offer senior discounts. We almost never cook at home—too much time and effort. We also take naps and rest breaks during the day. Even though we are active, we know how to use “activity portion control.” (they both laugh.) The most important thing is that we know our limits. We never rush and we stop when we are tired.
You know something else…that you didn't ask me about…my wife is about the strongest person I know. After going through that stroke and the aphasia…and at only 65…she can handle anything…and she has a positive attitude about everything since she has gone through all of this. We both do. I guess you could say we are older and better!
Mrs. B: Older and better (smile). I like that. “Me 82. Him 84. (Smiling) Me aphasia…and life more precious now.
Case # 2: Person With Traumatic Brain Injury
Ms. R is a 72-year-old Caucasian American single female who incurred a TBI after a motor vehicle injury 11 years ago. She was an office worker who retired after the TBI because of severe headaches and cognitive difficulties that interfered with her ability to carry out job duties. She is now a successful writer, her life's dream. She also regularly attends the monthly traumatic brain support group and is very supportive of the younger group members. Ms. R says that she lives an enjoyable, productive life, despite problems with fatigue, depression (treated with medications), chronic pain, sleep apnea, migraines, and cognitive impairments (memory and organization). Ms. R says she taught herself to compensate for the cognitive problems because insurance denied payment for cognitive rehabilitation (after funding an assessment that confirmed cognitive impairments). She stated, “I had to learn to help myself, because if I don't nobody will. I have trouble with organization, so I bought a fisherman's vest. Look at this!” She then proceeded to demonstrate an amazing organizational system she developed using the vest's “multi-pocket system.” The vest had a pocket for everything that she needs to have throughout the day (10 vertical pockets on either front side of the vest).
Ms. R expressed that she is doing well, but at a high cost. She said it takes her longer to carry out activities than before the TBI, and longer than for most people who have not incurred a TBI. She expressed the sense that life has lost its “spontaneity” because of the need for her to plan out every activity so that things “go smoothly.” Also of interest was her sense of “being in better health than her 72 year old peers despite the TBI.” She said that the reason she takes better care of herself (in terms of eating, obtaining adequate rest and regular exercise), is because of a fear that the TBI places her at risk for “accelerated aging.”
Case # 3: Person With Multiple Sclerosis
Ms. E is a 59-year-old African American, single female with a diagnosis of MS. She uses a cane to walk, but said that despite the cane “God orders her steps.” Her speech is characterized by moderate dysphonia and intermittent dysfluency. She had a series of spinal surgeries when she was between 55 and 57 years of age. This resulted in pain, numbness, and tingling in her lower extremities. She was not concerned when symptoms worsened at age 58, thinking they were due to complications of advanced aging, until she also experienced right eye blindness in the early Fall of 2013. MRI and spinal tap led to a diagnosis of MS in mid Fall 2013. Her acceptance of this recent diagnosis is remarkable. Ms. E says that since the diagnosis she “goes with the flow” in her quest to find the “new normal” for herself. Since the MS, she has more patience with herself, has become more in touch with the spiritual side of herself, and is now more “self-directed.” She retired early (at age 50) from her work in administration at a local business. She returns there to perform poetry that she writes as a hobby. She also attends the monthly Multiple Sclerosis Support Group, to which she used to bring her older sister (who also has MS) until her sister was placed in a long-term care facility because her medical condition significantly worsened. Ms. E says she has faith that God is with her every day to help her manage life's challenges, and that she is grateful for both good and seemingly bad circumstances because “God allows them all to happen.” Ms. E is not concerned about the communication impairments at this point and does not report having cognitive-communication difficulties. Ms. E has many supportive siblings, family members, and friends available to assist her, if needed.
Comments on the Cases
All three cases appeared to be adjusting well to both the aging and the communication disorder and remained actively involved in society (Activity Theory). Their involvements in community parallel activities engaged in during earlier points in their lives (Continuity Theory). Furthermore, all expressed acceptance of perceived losses (Kübler-Ross Five Stages of Grief) and a willingness to simplify and adapt their lives to compensate for those losses (the Wonder of Age Theory) in order to achieve full life participation. The Disengagement Theory was clearly not at play in the lives of these active and well-adjusted elders who were encountering the impact of both aging and communication/cognitive-communication disability.
These cases demonstrated that the aging process, the effects of disability, and the ways that people compensate for disability are unique to each person. Careful analysis of the stories shared, however, reveals a pattern of themes associated with successful aging and full life participation despite disability. This includes:
  1. A solid network of support by positive like-minded people (e.g., support groups)

  2. Internal drive/resiliency motivated by a sense of purpose (self-motivation)

  3. A consistently positive attitude (elimination of negative self-talk)

  4. A specific plan of action for self-help (and working that plan)

  5. A plan to build enjoyment into each day

  6. A well-paced life (setting up a daily schedule, setting limits, not rushing)

  7. Valuing self and expecting others to (having goals and dreams)

For each successfully aging case (described above), there are many more who suffer silently with the cumulative effects of aging and communication disorders.
Conversations, such as with Case #1 about aging and disability, using simple open-ended questions (and lots of listening) might also go a long way towards uncovering important social issues that could impact the success of treatment, life participation and overall quality of life (Grassman, Holme, Larsson, & Whitaker, 2012). Questions like:
  1. May I ask your age?

  2. What is it like being that age?

  3. Is it like you thought it would be? Tell me about that.

  4. Did the (communication disorder) change things? Tell me about that.

These cases highlight the importance of using WHO ICF-based approaches (Threats, 2006), such as the Profile of Functional Activities and Life Participation (Wallace, 2010) and Live Interests and Values (LIV) Cards (Helm-Estabrooks & Whiteside, 2012). These types of assessments serve as effective tools for unobtrusively obtaining comprehensive, case-centered information of relevance to the SLP and entire multidisciplinary team.
Closing Remark
Regardless of the amount of time left to live, each life is of value. For our elders, their gray is their wisdom; their wisdom is golden; and we are indeed blessed with the sacred opportunity to provide them with care.
References
Administration on Aging, Administration for Community Living, Department of Health and Human Services. (2012). A profile of older Americans: 2012. Retrieved from http://www.aoa.gov/Aging_Statistics/Profile/2012/docs/2012profile.pdf
Administration on Aging, Administration for Community Living, Department of Health and Human Services. (2012). A profile of older Americans: 2012. Retrieved from http://www.aoa.gov/Aging_Statistics/Profile/2012/docs/2012profile.pdf×
Amyotrophic Lateral Sclerosis Association. (2013). Who Gets ALS? Retrieved from http://www.alsa.org/about-als/who-gets-als.html
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