Gerontology Preparation In
Communication Sciences and Disorders
Sandra Glista, M.S.
Western Michigan University
Barbara B. Shadden, Ph.D.
University of Arkansas - Fayetteville
Gerontology education in communication sciences and disorders pre-professional graduate programs is necessary to meet the anticipated service demands of the growing elderly population. Demographers tell us that by the year 2040, the population of people over age 65 will increase from a current 12.6% of the population to a high of 21.7% of the people in the United States or over 70 million elders. Further, the fastest growing group of elders is those 85 years and older. This group of very old elders will eventually constitute nearly one-half of the over 65 population and, as a group, will have a greater number of impairments which will precipitate disabling conditions interfering with independence, pursuit of life interests, and communication.
Older adults are already underrepresented in the caseloads of speech-language pathologists and audiologists (Fein, 1983). This fact is alarming in view of the predictions of various federal workforce bureaus that demand for speech-language pathologists and audiologists will increase at a much greater rate (34%) through the year 2005 than the average rate (20%) for other professions (Berman & Cosca, 1992). Part of this anticipated growth rate is due to the graying of America. In addition, an increased emphasis upon early detection and prevention of communication disorders plays a role in increasing demand for professional services (ASHA, 1991). Given concerns about the current state of gerontological preparation in our undergraduate and graduate education programs, it is imperative that academic programs take stock of their current curricular and clinical offerings in gerontology and explore mechanisms for improving preparation in this area (Department of Health and Human Services, Public Health Service, 1996).
This workshop presents (1) rationales for gerontology preparation in communication sciences and disorders, (2) alternative models of gerontology curriculum, and (3) the results of three years of Project KEEP: Keep Elders Communicating, an allied health training project funded by the Department of Health and Human Services, Health Resource Service Administration (#ID37 AH00531-03) which demonstrates successful institutionalization of an infused gerontology curriculum in the Department of Speech Pathology and Audiology and Western Michigan University. Further, this presentation will focus upon what Project KEEP has taught us regarding the promotion and recruitment of speech-language pathology and audiology students to work with the elderly. Examples of specific, concrete, and successful curricular and practicum revisions will be shared in order to stimulate group discussion of opportunities and barriers within individual graduate programs.
Mandates for Gerontology Preparation
Mandates for improved gerontology preparation for speech, language, and hearing professionals and other allied health professions emerge from a variety of sources (Shugars, O'Neil, & Bader, 1991). Communication disorders professionals specializing in gerontology have commented on the current limitations of curricular content addressing normal aspects of aging in most speech-language pathology and audiology educational programs (Fox, 1994). Despite an already overcrowded curriculum, creative options for integrating geriatric information into our curricula have been proposed by academicians (Weinstein, Shadden & Clark, 1992). Included in these proposals have been demands for more clinical practicum experiences with elderly persons, and for experiences that reflect a more diverse group of individuals.
These mandates from practitioners are well-supported by policy statements and certification and accreditation requirements issued by the American Speech-Language-Hearing Association (ASHA). ASHA clinical certification standards state that academic course work must include courses addressing "issues pertaining to normal and abnormal development and behavior across the life span and to culturally diverse populations" (ASHA, 1997a, p. 10). The ASHA Certification and Membership Handbook goes on to indicate that implementation of this standard will take place through "all areas of academic course work, including Basic Science course work... and Professional Course work...[which]... must address issues pertaining to normal and abnormal human development and behavior across the life span and to culturally diverse populations" (ASHA, 1997a, p. 10).
Corresponding to and supporting this curricular expectation, the ASHA Council on Academic Accreditation in Audiology and Speech-Language Pathology (CAA) Accreditation Manual states:
The program's curriculum must be sufficient to permit students to fulfill Standard II of the ASHA Standards for the Certificates of Clinical Competence in the area(s) in which accreditation is sought, or it must demonstrate how its students meet those requirements. (ASHA, 1997b, p. 22)
Thus, through certification and accreditation mandates, and through various position statements, the Scope of Practice Statement, and the Code of Ethics, ASHA directly and indirectly supports the need for gerontologic preparation in communication disorders.
Before examining Project KEEP in more detail, it is helpful to review briefly three important questions about gerontological preparation: 1) where are we at present in our gerontology/geriatric curricular offerings; 2) what are our options in attempting to incorporate gerontologic content and practicum into preprofessional and professional education; and 3) is there a core content that should be addressed.
Where are we at present in our gerontologic/geriatric curricular offerings?
Very few studies exist which assess how well we are including gerontology education in pre- and professional education programs. In 1980, Nerbonne, Schow, and Hutchinson found that less that one quarter of the graduate programs offered or planned to offer gerontology related course work. Five years later, Raiford and Shadden (1985) found an increase of 5% in course work offerings, but the scope of courses was still very limited and very disorders based. Very few experiences with normal older adults were offered.
A more recent unpublished work by Clark, Ripich and Weinstein (1994) noted a marked change in the 90's. More than three quarters of programs reported the theme of aging adults was addressed in graduate courses. Typically, some type of infusion model was used rather than a separate course. Most respondents acknowledged the need for a course and clinical content and experiences, but experienced previously cited barriers to implementation such as constraints posed by finances, over-full curricula, faculty resistance, and lack of faculty preparation. Clinical experiences continued to be with disordered older adults and most practicum continued to be in acute care settings, rather than in those unique settings, such as in long term care, where aging issues and knowledge base are critical.
Another unpublished study by Peavey asked graduate students how they felt about their level of preparation to serve various age groups. Ninety-three percent of graduate students responded by saying they felt adequately prepared for work with young children, but only 45% felt prepared for work with older adults. These few surveys suggest we are making progress in gerontology curricular offerings, but that we have not reached our goal of educating students about normal and disordered aging processes.
Alternative Models of Gerontology Curriculum
Given these current limitations, what are our options in attempting to incorporate gerontology content and practicum into preprofessional and professional education? What are the advantages and disadvantages of each of the models listed?
Analogous to the curricular models proposed for multicultural education, five approaches to improve the incorporation of geriatric content into the speech-language pathology and audiology curriculum can be identified.
The Course Approach
One solution is a single multidisciplinary course in gerontology that provides an introduction to core content (biological, psychological, sociological information), but does not specifically relate content to communication and communication disorders. A single course provided by the communication disorders program with multidisciplinary input, as it relates to aspects of aging and attributes of the older adult followed by applications of basic aging information regarding assessment and intervention, is another version of the single course solution.
A problem with separate courses is that they tend to underplay the concept of lifespan developmental issues, placing inappropriate emphasis upon aging and the elderly as a totally separate process and group. Separate courses tend to focus exclusively on disorders, not on normal aspects. If both normal and disordered aspects of aging are included, students also seem to become confused about what is normal.
The Pyramid Approach
A series of courses pertaining to aspects of aging and older populations progressively expands the student's knowledge base and practical experience with this group and with a predetermined body of content information. This approach might allow inclusion of course offerings from other departments, as long as one or more integrative courses within the communication disorders program brings the information back into application to speech-language pathology and audiology concerns.
Elective courses from other disciplines fit best at the undergraduate level and may not be easily controlled before students enter graduate school. Even for undergraduates, making space in the curriculum is a problem for many students who may not be sure which population they would like to treat after graduation or who may have no clear idea of the needs of special age group populations.
The Unit Approach
In this approach, each course within the communication disorders curriculum includes one or more units which focus on information relevant to aging and the older adult. Units can be presented in a variety of fashions and by a variety of individuals. For example, in basic anatomy and physiology, units on the aging brain, the aging laryngeal mechanism, the aging respiratory system, etc., can be included or a single unit on the effects of aging on the speech mechanism could be introduced. The unit approach may look good on paper, but may be difficult to implement consistently unless there is someone overseeing and guiding the process.
In contrast with the unit approach, gerontological content is incorporated into each unit within a specific course as appropriate. Using the anatomy/physiology example, information about the effects of aging on the respiratory mechanism would appear in the basic unit on respiration. While the infusion approach is most preferred, its success is dependent upon individual faculty members having knowledge of appropriate content, where and how to infuse, and how to build in examples. Often, there is also resistance on the part of faculty who feel courses are already loaded with necessary content and who cannot see how to add more.
In addition to didactic classroom education, clinical experiences should include community based observations of and participation with normal older adults, supplemented by film and other vehicles as needed. A normative base for behaviors should be established before hands-on clinical training. Clinical training should then include specific experiences with communicatively disordered older adults. This is not as easy as it sounds.
Finding, creating, and monitoring experiences for students to interact with healthy, normal elderly is time consuming, adding to already over-scheduled faculty work loads. Additionally, motivating students to participate is difficult, when their focus is upon fulfilling their obligations to collect the clinical hours necessary for ASHA certification. Despite the inherent value of interactions with healthy elderly, opportunities to interact with such adults must be built into existing course work and not be burdensome to an already overfilled didactic and clinical curriculum.
Is there a core content that should be addressed?
In ASHA's (1988) position statement on "The Roles of Speech-Language Pathologists and Audiologists in Working with Older Adults," four key aspects of gerontological preparation were described as essential to developing appropriate competencies for working with elderly persons. These aspects were:
1. Knowledge of the nature of the aging process, the characteristics of older persons, and the influence of age-related changes upon communication behaviors (including experience with non-communicatively impaired older persons);
2. Knowledge of the types and characteristics of communication disorders associated with aging or found with increased prevalence among older persons, and experience with the appropriate forms of assessment and intervention for these disorders;
3. Knowledge of medical advances in assessment and treatment of disorders that affect older persons; and
4. Knowledge of and experience with techniques for modifying interventions to meet the needs of older clients, including awareness of current trends in programming for the communicatively impaired older person.
To guide faculty in attempting to define necessary content about normal aging, results from a foundations project from AGHE and GSA may be helpful (Johnson et al., 1980). The authors reported 90% of respondents agreed that a common body of knowledge was needed by all persons in the field of aging. Most also agreed that it was feasible to offer core content at institutions of higher education. Only 12 content areas were agreed upon as basic core items by 70% or more of respondents. In rank order, these were:
Project KEEP: Keep Elders Communicating
The remainder of this presentation will describe the foci, methods, and results of Keep Elders Communicating: Project KEEP, a preprofessional preparation allied health training project funded by the U.S. Department of Health and Human Services, Health Resources Service Administration. Project KEEP's primary goal has been to increase the quantity and quality of professionals in speech-language pathology and audiology who have specialized competencies for keeping elders communicating and for working with individuals from diverse cultures and in rural settings. The discussion of Project KEEP is presented in order to provide participants with a better understanding of how a comprehensive gerontologic preparation program can evolve out of a relatively traditional education framework. Project KEEP outcomes also demonstrate successful strategies and potential barriers to program implementation.
Five Focus Areas
Project KEEP has prepared speech-language pathologists and audiologists with special competencies. The five focus areas include the following:
1. Professional Methods and Assistive Technologies: diagnose, assess, and treat older Americans using the most meaningful and relevant treatment methodologies and technologies to keep them communicating;
2. Age, Family, and Culture: serve older Americans and make treatment decisions relevant to their age, family, and culture;
3. Interdisciplinary Teams: provide care within the framework of interdisciplinary health care teams;
4. Functional Setting and Outcomes: work with older Americans and their families, especially in rural locations, to enable rehabilitation of communication within functional life settings; and
5. Prevention and Participation: implement primary and secondary strategies for preventing communication impairment and disability among older Americans while promoting full participation in social and avocational settings.
The Project is meeting three key objectives:
Objective One: To prepare 20 per year or more graduate level speech-language pathologists and 4 per year or more graduate level audiologists, with specialized competencies in the above five area.
Objective Two: To identify and recruit highly qualified students who are most likely to meet the service delivery needs of elderly Americans in the targeted underserved communities. This includes prospective students who:
1. express interest in working with elderly people or
2. are members of racial or ethnic minority groups themselves or
3. have lived in rural communities.
Objective Three: To expand/develop the knowledge base to meet the needs of elderly people, especially those living in rural areas, and to disseminate information about the educational strategies and results of Project KEEP
Project KEEP has been implemented in three phases, corresponding with the three years of funding. Phase 1 emphasized curriculum modification and student recruitment.
Phase 2 emphasized relationships with off-campus practicum sites and community development activities. Phase 3 emphasized monitoring of graduates in their post-graduation employment settings relative to the purposes of the project. Students complete competency achievement self-evaluations before and after Project KEEP participation.
Key activities for graduate students in speech-language pathology and audiology who benefited from the project included:
Activities directed toward each objective have taken place across all three phases.
Modified Course work
First of all, curricular changes have taken place as a result of Project KEEP. Infusion of gerontological information into the existing speech-language pathology and audiology graduate level pre-professional preparation program has taken place. A sample course of graduate study in speech-language pathology and audiology is provided to document the sequence of courses students are required to complete.
Western Michigan University
Department of Speech Pathology and Audiology
Sample Course of Graduate Study
Special competencies are acquired in a series of unique course work and practicum activities. A typical course of study is as follows (key Project KEEP course work and practicum are indicated by italics and new ones marked by an "*"):
semester one semester two
Diagnosis and Appraisal Disordered Language Development
Normal Language Acquisition and Behavior Voice Disorders
Computer Analysis of Language Aphasia
Quantitative Description in Comm. Disorders
*Clinical Practicum in Adult Geriatrics *Clinical Practicum in Adult Geriatrics
Half-Term One Half-Term Two
Principles of Professional Practice Counseling for SPPA
Clinical Practicum Clinical practicum
*Community prevention program Dysphagia
Comm. Behavior and Aging
semester Three semester four
Advanced Speech Science Research Methods in SPPA
Motor Speech Disorders or Families and Multicultural or
Non-Speech Communication Cognitive/Comm. Disorders
Stuttering or Articulation Disorders
Off campus practicum *Off campus practicum
semester one semester two
Diagnostic Audiology Advanced Hearing Science
Hearing Aids Educational Audiology
Pediatric Audiology Diagnostic Audiology II
Quantitative Description in Communication Dis. Hearing Aids Seminar
Clinical Practicum Clinical Practicum
Half-Term One Half-Term Two
Principles of Professional Practice Industrial and Public Health
Seminar in Aural Rehabilitation Instrumentation in Audiology
Seminar in Geriatric Audiology Rehabilitative Audiology
Clinical Practicum Professional Field Experience
*Community prevention program
semester Three semester four
American Sign Language Thesis
Advanced Speech Science Independent Research
Research Methods in SP and Aud
Off-Campus Field Practicum Off-Campus Field Practicum
Some examples of specific modifications in didactic course work include the following.
SPPA 649 Normal Language Acquisition and Behavior: (3 sem. hr.). Taught by Nickola Nelson, Ph.D., CCC-SLP. Emphasizes contextual variation in language behavior and contextual influences on language-learning processes. Focuses on cultural and linguistic diversity, and on connections between home, school, and/or workplace communication, and between spoken and written language. Project related modifications included: (1) Students learned methods to collect and analyze language samples from elders; (2) students completed course projects to conduct mini-communication samples with elders; and (3) students learned communication discourse procedures for differential diagnosis of normal versus abnormal language form, content, and use in aging.
SPPA 653 Diagnosis and Appraisal: (3 sem. hr.). Taught by Jan Bedrosian, Ph.D., CCC-SLP. Emphasizes instruction in methods and procedures for evaluation of speech and language disorders. Project-related modifications included: (1) Students learned theoretical and best practice models of examination of the older adult; and (2) differential diagnosis of adult communication disorders emphasized recognition of the contribution of diversity and ethnicity in elders.
SPPA 640 Voice Disorders: (3 sem. hr.) Taught by Robert Erickson, Ph.D., CCC-SLP. Covers organic and functional disorders of laryngeal and resonator origin. Project related modifications included: (1) greater emphasis upon voice related problems in older persons, such as those in Parkinson's Disease; (2) primary and secondary prevention techniques for preservation of the normal voice in the aging adult; and (3) exercises listening to voices from a wide variety of healthy aging people.
SPPA 669 Principles of Professional Practice: (2 sem. hr.) Taught by Nelson. Emphasizes current professional, ethical, and philosophical questions with reference to the history of the profession of speech pathology and audiology. Project related modifications added the following: (1) students learned about the ethical issues of death and dying related to treating patients who are elderly; (2) students learned issues of hospice care, managed care, and health care finance; and (3) students learned about administration of community programs and supervision of paraprofessionals.
SPPA 649 Counseling for Speech-Language Pathologists and Audiologists:
(2 sem. hr.) Taught by John M. Hanley, Ph.D., CCC-SLP. This course surveys methods and practices for counseling persons with communication disorders. Project related modifications included: (1) importance of depression as a mental health disorder and symptom recognition in treating the elderly; (2) emphasis upon collaboration with interdisciplinary primary and allied health providers; and (3) application of family systems theory to counseling older persons and their families about communication disorders and their differential impact upon the family.
SPPA 645 Non-Speech Communication: (3 sem. hr.) Taught by Bedrosian. Alternative and augmentative communication (AAC) with severe communication disorders is the topic with focus upon strategies for technologies and restoration of functional communication. Project related modifications included: (1) specialized sensory, vocabulary, and functional communication needs of elderly using technological aids in AAC; and (2) assistive technology options for maintaining functional independent living among the elderly.
In the Audiology area, project modifications in audiology course work included an increased emphasis on understanding the influences of aging on families and individuals as well as on changes in hearing and communication. Information about cultural diversity and special concerns related to working in rural settings was infused across the curriculum as noted in the course modifications described below.
SPPA 622 Hearing Aids: (3 sem. hrs.) Taught by Gary Lawson, Ph.D., CCC-A. Hearing aids, working knowledge of the components, physical and electroacoustic characteristics, evaluation, selection, fitting, use and troubleshooting are considered. Project related modifications include: (1) specialized needs of the elderly in assessment ; and (2) counseling techniques and methods for working with the elderly and their families.
SPPA 639 Rehabilitative Audiology: (3 sem. hrs.) Taught by Harold Bate, Ph.D., CCC-A. Philosophies and competencies related to rehabilitation are covered in detail including use of counseling, assistive devices, speech skills, manual communication, and
others. Project related modifications include: (1) diagnostic and rehabilitative content unique to the elderly population; and (2) considerations of care for multicultural populations of elderly.
Normal Aging and Communication
As the Project KEEP progressed, additional course work and interdisciplinary activities emerged. For example, a course was added to address the issues of normal aging and communication. Communication Behavior and Aging explores the aging process as it relates to changes in speech, language, hearing and communication interaction across the adult life span. The course reviews societal impacts upon human behavior as it affects communication effectiveness and efficiency. Family perceptions of communication changes, as well as multicultural influences, are discussed. Community networks for services to adults and aging people are surveyed. Participation in a service learning/prevention project is part of the course. The role of speech-language pathologists and audiologists as community resources, advocates, and educators is emphasized.
Course objectives state, by the end of this course, students will be able to:
Student projects include participating in a communication disorder-based prevention activity or service learning project and conducting life-cycle interviews with healthy, community-dwelling elders. Student course evaluations indicated that the most worthwhile aspect of the course was the service learning project conducted with healthy elders in the community.
Specialized competencies were supplemented through expert consultant workshops (through live video-conference produced by ASHA). Two kinds of workshops are occurring: one national expert workshop per year and several community workshops. These workshops ensure that best practices are being modeled for the students in their off-campus sites and that continuing education takes place for regional practitioners in addition to our students receiving the most current and best practices advice in gerontology.
Development Of Model Practicum Sites
Over the course of the three years of Project KEEP, ten model practicum sites have been developed. Those sites, supervisors, and the speech-language pathology and audiology graduate students are committed to fulfilling the objectives of Project Keep by practicing with elders promoting the use of the most appropriate technologies, methods, and prevention procedures.
A unique relationship has been built with model practicum site supervisors through Project KEEP. Model practicum site supervisors attend three meetings on campus during each academic session. Meetings are held to communicate the objectives of Project KEEP to the supervisors, to profit from the advice of the community off-campus supervisors, and to provide information on pertinent topics and interests relative to provision of services to the elderly and also to supervision of graduate students. For example, meetings have provided instruction in university library resources and databases, utilization of the World Wide Web (Glista, 1997), supervisory techniques, and audiology practice in long term care settings. Similarly, supervisors have given their feedback and advice about Project KEEP during each meeting. Their full participation has had a most positive influence upon the off-campus model practicum site partnership with the university in the education of the graduate students.
Unanticipated Positive Outcomes
Collaboration between and among model practicum site supervisors and WMU faculty has become an unanticipated positive outcome. Several products and processes have resulted which were not planned. Model practicum site supervisors overwhelming commended Project KEEP faculty for bringing them together to convene and discuss issues related to delivery of communication services to the elderly. Model practicum site supervisors are motivated to develop ongoing meetings regularly on campus with faculty and students and discuss issues related to improving delivery of communication services to elderly beyond the life of Project KEEP.
Other positive outcomes which were unanticipated include the following:
(1) research projects on the topic of elderly and communication disorders completed by second year graduate students doubled in number; and (2) undergraduate writing projects with topics covering gerontology and communication disorders also doubled.
Problems Encountered with Project KEEP
Model Practicum Site Supervisor Availability - Although Project KEEP has been successful in recruiting model practicum sites and supervisors in rural and medically underserved areas, retention of qualified and certified professional model practicum site supervisors at these facilities has not been consistent. These changes leave not only vacancies in supervisory positions for Project KEEP, but also unfortunately, voids in provision of professional service to rural patients. While this situation is certainly beyond the control of Project KEEP, we regularly recruit other qualified model practicum site supervisors to work with Project KEEP in rural hospitals.
Lack of Traineeship Funding
Lack of availability of funding for student traineeships is a drawback for student participation. Graduate students in speech-language pathology and audiology endure serious financial obligations to complete their 4 year undergraduate and 2 year graduate programs. Students have stated they would be interested in participating more fully in Project KEEP if student stipends were available, particularly when off-campus rural practica require additional funds for travel from campus to rural sites.
Lack of Students Choosing Care of Elderly as Career Objective
Additionally, students have a wide choice of options in selecting an off-campus professional field experience. When choosing field placements, students often opt to select the acute-care medical setting rather than long-term care because of the perceived stigma of nursing homes or long-term care settings. A student stipend incentive would be a boon to student participation to overcome perceived drawbacks.
The curriculum in speech-language pathology and audiology is crowded by the large amount of information that must be covered in the two years of graduate study. Insertion of additional content relative to aging and the elderly is proving to be successful, but also challenging.
Any curricular revision undertaken by departments benefits from institutional support from the underlying university or college mission statement. This has certainly been true for Project KEEP and its ultimate implementation and sustainability beyond its funding for three years. In fact, college-level institutional support has been so strong that funding for the new course and service learning projects has been guaranteed.
Also inherent to successful development and implementation of a gerontology/ geriatric curricular model are adequate human and instructional resources. External funding insured human resources for planning, instructional resource gathering, and faculty mentoring. A significant part of the value of an independent and individual training grant, such as Project KEEP, has been the advantage of assigned time for a faculty member to develop the program.
Finally, faculty dynamics play a significant and crucial role in the ultimate success of implementation. Using the infusion model presumes collaboration, cooperation, and collegiality among the faculty. Individual members of the faculty must feel comfortable critiquing their own courses, accepting advice or suggestions from peers, and utilizing and incorporating the expertise of their colleagues.
In closing, Project KEEP: Keep Elders Communicating presents one example of a systematic approach to address multiple needs in gerontologic preparation. It is provided to stimulate discussion about other ways in which programs can build such preparation into their own unique contexts with their own individual constraints.
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Much of the work reflected in this presentation was supported by Keep Elders Communicating: Project KEEP, a pre-professional preparation allied health training project funded by the U.S. Department of Health and Human Services, Health Resources Service Administration (1 D37 AH00531-03)