Do You Hear What I Hear?
by Teepa Snow, MS, OTR/L, FAOTA
It’s so much more than a line from the Little Drummer Boy, a Christmas song. Recognizing that temporal lobe function is complex and diverse is critical in continuing to offer support and interactions that work for someone who is beginning to develop brain changes. Noticing that you and another person may not be:
- taking in the same auditory data
- blending the data from each side in the same way
- processing the language component of the data at the same speed or in the same way
- connecting the auditory information with the same memory files
- using contextual cues or facial recognition information to connect names and relationships to faces in matching ways
- using the same words to describe the same items or actions even though that is the intent
Recognizing the changes is critical for an effective interaction and sustaining changing relationships. Appreciating the changes that happen in the temporal lobes when someone is living with dementia, can dramatically alter how we decide to communicate, interact, and engage with one another for better outcomes. It can also provide us with almost magical opportunities for experiences that bring joy, satisfaction, comfort, and pain relief when we use what remains available and is powerful for someone who is living with dementia and those who would offer support and care.
Failure to be aware of the differences and changes, not making changes in our expectations or behaviors, and not learning new communication strategies and skills can damage valued relationships and create huge problems. Emotional distress and frustration can impair the quality of life for just about everyone involved in the life of a person experiencing neurodegeneration. If a care partner or supporter doesn’t realize what is going on, or if a supporter doesn’t know about the difference between being hard of hearing and being hard of comprehending, there are multiple missed opportunities and major misunderstandings.
For a deeper understanding, continue
Here are some of the ways in which the changing temporal lobe abilities might be changing relationships and interactions.
The person of interest can think the carer is yelling at them when increased volume or greater intensity of tone is used to get a message through. Actually, the person is increasing volume and emphasizing each word to try and overcome what is thought to be a hearing loss. The unaware carer doesn’t realize their facial features are changing into a more threatening pattern, their stance immediately in front of the person is blocking any way out of the interaction, their tone makes them sound angry or distressed, if they lean in towards an ear or face, they seem to be attacking, and their arm and hand movements can be slightly out of the central field of sight creating a greater sense of danger.
How did this misunderstanding start? The person living with dementia may use the automatic rhythmic verbal reaction of What?, Eh?, Pardon?, or Huh? when they can’t get the words that are being delivered. The challenge for the supporter, is noticing if the challenge with delivering the message is:
- A hearing problem that can be remediated by a hearing assist device
- A hearing problem that is not helped by a hearing device to make human speech clear enough to capture
- A hearing problem that is more related to background and foreground noise or ability to filter important from irrelevant information
- A hearing problem with selected pitch or tonal ranges
- An inability to tolerate a device that amplifies sound due to other auditory processing issues such as tinnitus (ringing in the ears), sensory issues with glasses and hearing aids, or emotionally charged issues of blocking ear canals due to life traumas
- An inability to get the message in the sound
- Inability to take the vowels and consonants in a way that allows for processing of words, sentences, and meaning in context
- Inability to take in language and attach meaning for functional purposes
- Inability to match the sounds with internally stored words and the visual representation on the object, person, situation, activity, or place
- Other possible issues
How could we determine what is happening? At Positive Approach to Care® (PAC), we use a formalized approach and connection to improve the probability that we have assessed for abilities. Rather than assuming that what the person could do before is what they can do now, we check it out.
- We use our Positive Physical Approach™ (PPA) pattern to seek permission to interact, minimize confrontational mistakes, and optimize engagement. We do it by approaching from the front of the person (the place where if they are looking or do look up, they can find us), pausing at an entry way or at least six feet away, and letting them know you are coming with a knock, knock on a surface or with your voice. This process allows us to screen for hearing problems, check out speed of processing and responding, notice visual recognition indicators, confirm ability and willingness to engage indicators, and determine alertness level.
- After we get permission to approach, we get into a supportive stance and either maintain a Hand-under-Hand® (HuH) clasp or place ourselves slightly beyond intimate (arm’s reach) space. We turn our face towards the person, but not our chest or body. This provides a full visual regard of our facial features along with a clear pathway for sound to travel from my mouth to your ear, while also allowing the person an avenue of visual escape, physical escape, and a mutual central field space of visual information sharing.
- Once we are in this position, we offer Positive Personal Connectors (PPCs). These allow us to begin to better determine verbal interaction skills and language abilities without causing distress. We use what we picked up from the PPA portion of the interaction to keep us on track for a solid interaction. In this section we find out how the person is taking in data. Do visual, auditory, or sensory-motor cues work better or in combination to deliver messages and get feedback? How quickly can the person take in, process, and deliver a response.
- Then, it is on to using Positive Action Starters (PASs). These queries or questions foster responses or answers that move us forward together. We can seek out more information, we can guide in getting something started, we can foster choice or decision making, and we can build a relationship for this interaction that is positive and supportive.
So once again, consider, why are the temporal lobes so vital to relationships? They handle all things auditory. Sections of these lobes also handle the connection between sounds that are heard and the context in which they are heard combined with visual information to understand the place, time, and situation. A small section of the temporal lobe allows for facial recognition and attaching name and relationship of that face to the person. A separate interpretation of emotions in both face and voice, expression of emotion through pitch, speed, intensity, volume, and repetition, the understanding of and production of language, and the connection between sounds, rhythms, and emotions of pleasure, sense of threat, sense of comfort, feelings of sadness or anger, that are tied to being human or life experiences. Deep in the temporal lobes, the hippocampal structures and connections provide storage and connections for memory formation for sounds, scenes, contexts, and events.
One area of the brain that is not typically diminished by dementia is the ability to hear sounds. The person can typically hear as well as they ever could. One of the challenges we can face, however, is the reality that common aging changes do impact the hearing structures of about 75% of all older adults. The ability to detect higher pitched sounds and distinguish consonants is lost with increasing age and environmental exposure to loud sounds throughout a life time. So, both factors may be impacting our interactions. Fixing one without addressing the other will not necessarily change the communication or interaction outcomes.
For people who are living with dementia, the problem frequently lies in three related functions: the ability to know where a sound is coming from in a space, the ability to follow a multi-person conversation in a non-structured setting, and the ability to sort out background from foreground noises, otherwise known as selective hearing.
The ability to localize or place the sounds in space is impaired as wiring across the middle of the brain is damaged and destroyed by dementia. Our ears are placed in such a way on our heads that each contributes approximately half the data, side specific. When the two ears work in combination, a person can detect sound from throughout a 360o spherical space. Each ear sends its data into that temporal lobe and the wiring across the center of the brain allows the two sides to integrate the data and determine where in three-dimensional space the sound originated. Keeping the ability to hear with each ear, but losing the ability to integrate the two sides into a whole can make overhead speakers, TVs, paging systems, or calls from another room challenging or difficult to comprehend. The person may think someone is talking to them, that a news broadcast is a conversation, or that an announcement meant for a staff member or someone else is meant for them. In some cases, they may think people are talking about them, arguing with them, or whispering to them.
This loss of ability for the two sides of the brain to work together also impairs their ability to determine who is actually speaking to them in a busy environment or when multiple people are taking part in a conversation and have to be located simply by where they are situated. Slowing the exchanges down, having one person offering one conversational back-and-forth at a time, offering visual signals when starting to speak, and placing people who are speaking near one another and to the right-hand side of the person, rather than in a circle or throughout a room can simplify the set-up and improve the interaction.
There is also a significant difference between the left and right lobes, when it comes to language skills. Over 98% of all humans isolate their language skills, vocabulary, speech comprehension, and speech production to the left-hand side of the brain. The right-hand side of the brain has a stronger role in non-formal speech skills. These abilities are more automatic and less formal, rhythm related skills. In dementia, there is a much greater preservation of the rhythm-related skills and emotional memory abilities, compared to formal language skills and specific memory skills. Increasing difficulty when trying to find and use specific words is one of the early indicators of many forms of dementia. The person who is starting to experience the symptoms of dementia and typically knows what they want to say, but cannot get the word to come to mind or come out. They may try to talk around the word, using alternative words or seeking to try to get to the word by describing it in other terms. This is called circumlocution. For instance, I want to go to the place where we get the things that I like to read. You know, the place where you take them out and then you take them back. Fairly early in several forms of dementia, this phrasing may be used instead of, I want to go to the library.
As dementia progresses there are several paths that language loss can take. The person may use more vague, non-specific words. When that happens, nouns tend to disappear and the person may have challenges trying to get others to understand what they are talking about or who they are describing. An example might be, She gave me the whatchamacallit and I put it in the thing to do it, with it. This sentence is meant to share that, My daughter gave me a dirty dish towel to put in the washing machine so it could be washed.
In other cases, the person may use word substitutions. The person replaces one word for another that has the same sounds, starting letter, or number of syllables. For example, the person may say, I want some coconut. When you offer some flaked coconut, they look at you with confusion, and say, What’s this? and your say, It’s coconut, that’s what you asked for. The person may then become frustrated stating, I asked you for coconut, not this! If you are not tuned into the substitution, you may find yourself at a loss or becoming irritated, since on the surface, it seems illogical and irrational.
In fact, there are two different skills being affected by their dementia. Language has two sides to it. Receptive language, the ability to comprehend what others say, and expressive language, the ability to say what you think. The challenge for this person is that their brain currently believes the correct word for the thing they want is coconut, the word for what they want is actually chocolate. Unfortunately, their visual recognition of the item you bring is on target, white flaky stuff, but not at all what they want. The dysfunctional part is that for the moment the name of the thing they want is not available at this time. Unless you recognize the challenge they are facing with being able to communicate what they are thinking versus saying, switch gears and go to another way of trying to get their message, offer an apology for not getting what they wanted, and try some other communication strategy, this interaction is unlikely to improve.
While, in this deeper dive, I covered many of the temporal lobe functions that are impacted by dementia, I have actually only scratched the surface. It’s is so important that we stay curious, authentically seeking to better understand what is happening, and approach each situation with compassion and a desire to empower. I hope this information is helpful and allows you to explore what might be changing, what might be possible, and what you can do about it. If so, then I think I might have gotten my message across.
Below is an additional article for further thought:
Bates, Mary. Super Powers for the Blind and Deaf: The brain rewires itself to boost the remaining senses. Scientific American website, posted September 18, 2012.