Speech-language pathology services in a skilled nursing facility: A retrospective study

Speech-language pathology services in a skilled nursing facility: A retrospective study


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13 ( 1980), 93 - 103




Upstate Medical Center, Syracuse,


New York


Syracuse University

The profession of speecl+language pathology has become increasingly involved in provision of services in skilled nursing facilities and other institutions for rehabilitative and long-term care for the disabled and/or elderly adult. Information concerning the characteristics of this population and other related issues, however, is slight. Medical and speech pathology records from a large skilled nursing facility were examined and analyzed with respect to eight variables. Patients referred for speech language evaluation over a 3-yr period comprised the sample. Results are discussed in terms of the implications of the major findings for professional training of the speech-language pathologist and the need to address the issue of role definition in institutions providing long-term care.

Introduction The profession of speech-language pathology has become increasingly involved in skilled nursing facilities and other institutions which provide combined rehabilitative and long-term care for the disabled and/or elderly adult. Projected demographic trends point toward a continuing increase in the importance of such sites in the delivery of professional services in speech/language rehabilitation. There is, however, a paucity of literature concerned with the characteristics of the population to be served and other related issues such as average length of treatment and therapeutic outcomes. There appears to be a need for such a literature to emerge in order to enable training programs and forums for continuing education to function effectively in the preparation of professionals who engage in provision of services in these settings. There also appears to be a need to begin to identify and define the issues, problems, and special challenges inherent in service delivery in facilities of this type. The purpose of the present investigation was to provide a description of the population referred for speech pathology evaluation and possible treatment, over a 3-yr period, in a 274-bed skilled nursing facility in a metropolitan area. In addition, data from speech pathology and medical records were examined with a view toward providing information relative to results of treatment. Address Jamesville,

editorial correspondence NY 13078.

0 Elsevier North Holland,

Inc., 1980

to: Pamelia

F. O’Connell,


6355 Westerly



1 1$01.75





Medical and speech pathology records for 108 consecutively referred patients in a skilled nursing facility were examined with attention to the following variables: 1. 2. 3. 4. 5. 6. 7. 8.

Patient age; patient sex; patient diagnoses: medical; patient diagnoses: speech-language pathology; number of treatment sessions and length of treatment in months; patient participation in occupational therapy/physical therapy; reason for termination; degree of change in status of communication skill according to a 4-point scale: a. no improvement; b. slight improvement; c. moderate improvement: d. significant improvement.

The segment of the population which was referred and evaluated, but not treated, was examined with respect to the first three variables plus an additional one: reason for decision of no treatment. In addition to descriptive statistics, correlational and multiple regression procedures (Cohen, 1966) were employed to assess the relationship between age, sex, diagnoses. and length of treatment and amount of improvement. Comparisons were also made between the treated and untreated patient groups. Results Data for treated and untreated groups were tabulated and analyzed separately. Age and s&x distributions for the treated group are shown in Table 1. Well over half the population was 70 yr or older, with the decade of 7&7Y showing the largest number of individuals. The age range indicates a heterogenous group, however, with some teenagers, young and middle-aged adults represented within an essentially geriatric population. The expected high proportion of females was found. With respect to medical diagnoses (Table 2), 62% of this group had multiple diagnoses. Out of an extensive array of medical terminology, nine disorders or groups of disorders were identifed as frequent-occurring designations, six of them with presumed etiological significance for communication disorders. Other low-frequency or accompanying disorders were grouped in a final category. The expected high incidence of left cerebrovascular accident (CVA) (61%) was found. When all CVA cases were considered, they constituted a very high (86)





TABLE 1 ,Treated Group: Age and Sex (N=54)

Range Mean Median Mode

18-82 66 71 71

Below Age 50 50-59 60-69 10-79 80-82

No. 6 9 8 24 I

% Il.1 16.7 14.9 44.4 12.9

sex Male Female

18 36

TABLE 2 Medical Diagnoses* N = 54 **I)

**2) **3) * *4) **5) **6) 7) 8) 9) IO)

Left cerebrovascular accident Right cerebrovascular accident Multiple or brainstem CVA Trauma Tumor Neurologic disease process (Parkinson’s, Multiple Sclerosis, etc.) Cardiac disease Organic brain syndrome Seizure disorder Other (diabetes, alcoholism, laryngectomy, Paget’s disease, degenerative arthritis, etc.)

* 62% of the population had multiple medical diagnoses, therefore, the percentages than 100. ** Diagnoses with primary etiological significance to communication disorders.

Treated Group

61% 14% 11% 1.8% 5.5% 3.7% 25% 1.8% 5.5% 42%

sum to greater

percentage of those who received speech-language services. The incidence of reported organic brain syndrome (OBS) was quite low. However, no medical screening for OBS existed in this facility and the reported incidence may not reflect the true incidence. This is viewed as unfortunate in that any relationship between OBS and amount of improvement in communicative ability may have been obscured.




The speech pathology diagnoses are reported in Table 3. Of interest are the multiple diagnoses which indicate that, while aphasia emerges as the leading diagnosis, this condition was accompanied by other conditions which affect communicative behavior in almost half of the cases. Coexistent aphasia and dysarthria was fairly frequent. Oral-verbal apraxia was not found in isolation, but only accompanied by aphasia. The data for aphasia were further analyzed as to severity and type (Table 4). The low percentage of “moderate” aphasics is noteworthy and tends to confirm the notion that, clinically, aphasia presents an essentially bimodal (mild-severe) distribution. All of the mild aphasics were classifed as anomies while all of the fluent aphasics were classified as severe. Anomia is sometimes designated as a type of fluent aphasia (Goodglass and Kaplan, 1972). Here the term “anemic” was used as a category for those aphasic patients with word-finding problems in the context of good speech and auditory comprehension, while the term “fluent” was reserved for those who exhibited fluent, phonologically disordered speech. The number of treatments and the length in months of speech pathology treatment services are shown in Table 5. The mean figures reported were influenced by a single case with an unusually long treatment period. The median figures probably best reflect the central tendency which wwas toward relatively short (2.5 mo) treatment periods. However, as shown in Table 6, almost half of the population was terminated from speech-language treatment due to discharge

TABLE 3 Speech Pathology


1) Aphasia 2) Oral-Verbal Apraxia 3) Dysarthria 4) Laryngeal Pathology 5) Language of Generalized

Treated Group





38 5 20 4 7

70 9 31 7 12

8 5 5

40 25 25 5 5

Multiple Diagnosis N = 54 I) 2) 3) 4) 5)

Aphasia and Dysarthria Aphasia and Apraxia Aphasia and Confusion Dysarthria and Confusion Laryngeal Pathology and Confusion

* 38% of the population to greater than 100.

had multiple speech pathology




the percentages







TABLE 4 Aphasia: Severity and Type N = 38 Severity Mild 9 23.6%

Moderate 5 13.3%

Severe 17 44.7% 63% severe or global

Global* 7 18.4%

Fluent 6 15.8%

Global 7 18.4%

Type Anemic 12 31.5%

Nonfluent 13 34.3%

* Detined as: No functional speech and no measurable



TABLE 5 Number and Length of Treatment Number of Treatments Range Mean Median Mode

38938.8 21 9


394.4 2.5 1


Length in Months Range Mean Median Mode


1) Discharge from Facility 2) Plateau (patient achieved maximum benefit from treatment and/or patient no longer exhibited positive change) 3) Failure to profit 4) Died

46.3% 18.5% 29.6% 5.6%




and not due to having achieved maximum benefit. The high (29.6) percentage of patients discharged due to failure to profit also contributed to the relatively short median treatment period. Those patients who were discharged while in the process of receiving treatment added to those terminated due to failure to profit contributed of-change findings reported in Table 7. While less than one-third

to the degreeof the treated

group were judged to have shown moderate or substantial improvement, only 18.5% were terminated for having achieved maximum benefit. While additional statistical procedures were employed, all significant relationships emerged in the correlational data. Significant positive correlations were obtained between length and number of treatments and degree of change for communicative status 0, < 0.05). Left cerebrovascular accident was positively correlated with age VI < 0.01) and with aphasia 0, < 0.01) while trauma was negatively correlated with age (p < 0.01). Significant negative correlations were obtained between age and degree of change (JJ < 0.05) and between age and length of treatment @ < 0.05). With respect to medical and speech pathology diagnoses, only one significant correlation was obtained. Dysarthria was negatively correlated with degree of change 0, < 0.05). Also negatively correlated (but not meeting the 0.05 level of confidence) with change were the following medical diagnoses: right CVA, multiple CVA, cardiac disease, organic brain syndrome, tumor, and CNS disease. Data for the untreated group are shown in Tables 8 - 1 I. Age and sex incidences were similar to the treated group. The medical diagnoses differ in the relative proportion of left and right CVA. One-third of the found to have identifiable communication disorders individuals were eliminated, the remaining group was group. Untreated aphasics and dysarthrics are further 13.

untreated group were not of any type. When these quite similar to the treated described in Tables 12 and

Six dysarthric patients were discharged before scheduling could take place. The remainder were either uncooperative or terminally ill. Treated and untreated aphasics were combined in Table 14, which resulted in accentuating

the essentially



of the severity


TABLE 7 Degree of Change 1) 2) 3) 4)

No improvement Slight improvement Moderate improvement Substantial improvement

* This group shows a substantial

overlap with the group discharged

3s.9?70* 31.5% 24.17c 5.6%

for failure to profit






TABLE 8 Untreated Group: Age and Sex (iV = 54)

Age 17-97 67 72 78

Range Mean Median Mode

6 5 14 20 9

Below age 50 50-59 60-69 70-79 80-97

23 31

Male Female

TABLE 9 Medical Diagnoses*: ** 1) **2) **3) **4) **5) **6) 7) 8) 9) 10)

Untreated Group (IV = 54) 38.8% 25.9% 7.4% 7.4% 9% 7.4% 18% 14% 0% 35%

Left cerebrovascular accident Right cerebrovascular accident Multiple or brain-stem CVA Trauma Tumor Neurologic disease process Cardiac disease Organic brain syndrome Seizure disorder Other

* 7 1% of the population had multiple medical diagnoses, therefore, the percentages than 100. ** Diagnoses with primary etiological significance for communication disorders.

sum to greater

TABLE 10 Speech Pathology 1) 2) 3) 4) 5) 6)

Aphasia Apraxia Dysarthria Laryngeal pathology Language of generalized No problems


Untreated Group

intellectual impairment

25.9% 18% 29% 0% 14% 33%



and E. .I. O’CONNELL

TABLE 11 Reason for No Treatment 1) 2) 3) 4) 5)

No need for therapy Died or discharged before scheduling Refused therapy Unresponsive Problems not amenable to speech pathology

33% 19.5% Il.l% 19.5% *16.77c


* These 9 patients exhibited: (7) severe intellectual deficit with multiple medical diagnoses; advanced astrocytoma; (1) S.P. removal of colloid cyst with uncontrolled ballistic movements.


TABLE 12 Untreated Aphasics: Type and Severity (N = 14) Anemic Nonfluent Fluent Global

I* 3** 2*** 8

* Refused treatment. ** One refused; 2 discharged *** Both discharged.

TABLE 13 Untreated Dysarthrics: Severity Mild Moderate Severe

Severity and Etiology Etiology

10 4


Cerebrovascular CVA (L&R) CVA (M) Tumor Cerebral Palsy

II 1 2 1

Discussion Several findings of the present study seem to have considerable relevance to the general topic of professional preparation and competency in the field of speechlanguage pathology. If the data presented here is at all representative of skilled nursing facilities, in general, the following points merit consideration. The advanced age of the majority of the population to be served suggests that the speech-language pathologist should be familiar with many aspects of older






TABLE 14 All Aphasics: Severity and Type (N = 52) Severity Mild 10 (19.2%)

Moderate 7(13.6%)

Severe 20 (38.4%)

Global 15 (28.8%)

Fluent 8 (15.5%)

Global 15 (28.8%)

Type Anemic 13 (25%)

Nonfluent 16 (30.7%)

adulthood, including normal and abnormal aging. There is some question, at this date, as to whether or not training programs have responded to this need,’ and according to Carmicheal (1975) communication and communication disorders have not, to date, been widely reprekented within the interdisciplinary field of gerontology. The multiplicity of medical diagnoses and of the terminally ill reported reinforce the fact that the skilled nursing facility or nursing home is, in fact, a medical setting. Again, there is some question as to how adequately speech language pathologists are trained to function within medical settings (Rubens, 1978). There appears to be a need for a more extensive investigation of this issue and/or for initiation and expansion of course work in adult disorders of speech and language, medical terminology, and gerontology. Over 96% of the population described in this study received physical and occupational therapy. Again, the question arises as to the extent that the speech language pathologist has been prepared to interface effectively with these disciplines. The over-all degree of change in communication status reported was slight. These results were disappointing to the investigator who also served as the clinician. A number of issues arise. First, the rating scale was judgemental and subjective and perhaps insensitive to small changes. However, in many cases, standardized test scores (Minnesota Test for the Differential Diagnosis of Aphasia, Boston Diagnostic Aphasia Examination, Token Test, etc.) were used to quantify degree of change. If one accepts the somewhat negative results of treatment as valid, there are several factors to be considered. One is concerned with the effect of length of treatment. It appears that relatively brief treatment

‘Following completion of this investigation, results of a survey of training programs (Hutchinson, J.M., Nerbonne, M.A., Schow, R .L. and Christensen, J.M., ASHA, 1978) indicated that only 21% of 190 programs surveyed offered a course in gerontology.




periods are ineffective, an implication also suggested by Vignolo (1964). Another concerns the aphasic groups, in particular. Although the amount of change in communicative status did not show a significant positive correlation with the diagnosis of aphasia, treated aphasics, as a group, showed greater improvement than the treated group as a whole (mean score = 2). A very high percentage of the aphasics was classified as either severe or global, while the “moderate” group was the smallest of the four on the severity continuum. Yet the standardized assessment tools for aphasia are aimed toward measurements of moderate involvement (Brookshire, 1973). Further, many of the treatment procedures and available materials are most useful for the moderately impaired. Much of the research literature reports investigations of this group. While the moderately impaired aphasic may well be the most interesting and possibly most instructive research subject, there is an obvious need for the clinical aphasiologistispeechlanguage pathologist to have an extensive background in the assessment and treatment of the more severe aphasic syndromes. Yet it is somewhat doubtful if this “extensive background” is available for acquisition. The literature on treatment of the severe/global aphasic is small and primarily concerned with failure (Sarno, Silverman, and Sands, 1970). This investigation does not pretend to add to this record in a positive fashion but attempts to reinforce the need for 1) increased recognition of the problem posed by severe aphasia, 2) initiation of research aimed at amelioration of communication deficits associated with severe aphasia, and 3) wider dissemination of information relating to treatment approaches for this group. The alternate forms of communication (communication boards, visual symbols, manual communication. and electronic devices) which have recently been shown to be effective with many other severely impaired individuals, have not. to date, proved a great value for the severe aphasic. Another point has to do with the influence of age on improvement. Amount of improvement was negatively correlated with age in this study, a tinding that has emerged again and again. Age is always listed as a poor prognostic sign (Eisenson, 1976). The pertinent question now appears to be why? That is. what processes associated with aging are responsible for the poor recovery of language function shown by this group? This, in turn, suggests that more research into language changes associated with normal aging is needed. A final point has to do with the role played by the speech-language pathologist in the nursing home setting. If the results of treatment in these settings are, for many of the patients, insufficient to effect adequate communicative behavior. then perhaps more attention should be paid to the environment in which they must attempt communication (Lubinski. 1977). This. in turn, suggests that inservice education, family counseling, and instructive interaction with all significant individuals must be one of the primary responsibilities of the speechlanguage pathologist and that this role must be recognized not only by the






individual clinician but by others as well. The major burden, however, is ours. If we represent independent health care practitioners we must define our own role and not allow others to do it for us. It is hoped that, as the profession matures, we will not only become more assertive in role definition but that we will become more capable of providing effective and well-informed clinical service. References Bookshire, R. (1973). An Inrroduction fo Aphasia. Minneapolis: BRK Publishers. Carmichael, C. (1976). Communication and gerontology: Interfacing disciplines. Sp. Common. 6: 121-129. Cohen, J. (1968). Multiple regression as a general data analytic system. Psycho!. Bull. 69: 426-443. Eisenson, Jon (1977). Language rehabilitation of adult aphasics. In Rationale for Adult Aphasiu Therapy, University of Nebraska Medical Center. Goodglass, H. and Kaplan, E. (1972). The Assessmenr of Aphasia and Related Disorders. Philadelphia: Lee and Febiger. Lubinski, R. (1977). Geriatric communication in institutional settings. Paper presented at Annual ASHA Convention, Chicago. Rubens, A. (1977). What neurologists expect of clinical aphasiologists. In Clinical Aphasiology Conference Proceedings. R. Brookshire (ed.), Minneapolis: BRK Publishers. Same, M., Silverman, M. and Sands, E. (1970). Speech therapy and language recovery in severe aphasia. J. Speech and Hearing Res. 13: 607-623. Vignolo, L. (1964). Evolution of aphasia and language rehabilitation: A retrospective exploratory study. Correx 1: 344-367.