CG 24(3-4) ONLINE.VP A Comparison of the Effects of Toys versus Live Animals on the Communication of Patients with Dementia of the Alzheimer’s Type Kari L. Greer, MS Karen A. Pustay, MS Tracey C. Zaun, MS Patrick Coppens, PhD ABSTRACT. The purpose of this study was to determine the effect of toy versus live cat stimuli on the verbal communication of elderly nursing home residents with dementia. The subjects’ verbal communication was analyzed for total number of words, meaningful information units, and ini- tiations. The measurements were recorded in three conditions: without stimuli, in the presence of two toy cats, and in the presence of two live cats. Six female nursing home residents with moderate dementia were ran- domly assigned into two groups to counterbalance the order of the condi- tions. The results indicated that live cats had the greatest influence on average subject performance across all three measurements. [Article cop- ies available for a fee from The Haworth Document Delivery Service: Kari L. Greer, Karen A. Pustay, and Tracey C. Zaun are all affiliated with the Min- nesota State University Moorhead. Patrick Coppens is affiliated with Plattsburgh State University of New York. Address correspondence to: Patrick Coppens, PhD, Plattsburgh State University of New York, Communication Disorders and Sciences, Sibley Hall, Plattsburgh, NY 12901 (patrick.coppens@plattsburgh.edu). The authors wish to thank the staff of Bethany Homes in Fargo, ND, for their help in conducting this study. Particularly, the support of Margaret Dahl, Loraine Kummer, Muriel Danielson, and Trudy Dura was greatly appreciated. Funding for this study was provided by a Learning by Doing grant from the Minne- sota State Colleges and Universities. Clinical Gerontologist, Vol. 24(3/4) 2001 http://www.haworthpressinc.com/store/product.asp?sku=J018  2001 by The Haworth Press, Inc. All rights reserved. 157 http://www.haworthpressinc.com/store/product.asp?sku=J018 1-800-HAWORTH. E-mail address: Website: © 2001 by The Haworth Press, Inc. All rights re- served.] KEYWORDS. Dementia of the Alzheimer’s type, pet therapy, verbal communication Referring to the dangers of dementing illnesses, Schwartz (1999) asserted, “The longer we live the greater the risk” (p. xi). Indeed, ten percent of Ameri- cans age 65 and older are stricken with DAT, and half of Americans over the age of 85 are afflicted with dementia of the Alzheimer’s type (DAT). Approxi- mately 4 million people currently suffer from this disease. By the year 2050, this number is projected to increase to 14 million (Bellenir, 1999; Churchill, Safoui, McCabe, & Baun, 1999). DAT is not a normal part of the aging process (Bellenir, 1999). It is a neuro- logical disorder that slowly advances in stages and affects cognition in terms of memory, reasoning, abstraction, and personality (Churchill et al., 1999). This progressive deterioration of memory often negatively influences linguis- tic communication. Bayles and Kasniak (1987) indicated that this is a primary feature of DAT. These deficits may be represented by difficulties with re- trieval and generating meaningful communication (Hopper, Bayles, & Tomoeda, 1998). McCallion (1999, as cited in Curtright & Turner, 2000) added that individuals with DAT show limited content and concept under- standing in their conversations. Intervention targeting these difficulties can be conceptually divided into in- ternal and external methods. Internal methods focus on improving the cogni- tive functioning per se, whereas external methods aim at improving communi- cation mostly by manipulating the environment, such as milieu therapy (Coons, 1981). Following the external approach rationale, previous studies have considered the effects of toys on the communication of the elderly (Fran- cis & Baly, 1986; Hopper et al., 1998). Hopper et al. (1998) indicated that the presence of toys may result in a decreased need of free recall during conversa- tion. In other words, toys can serve as a shared referent for meaningful com- munication. They found that the presence of a plush animal resulted in an increase in information units for persons with DAT. Francis and Baly (1986) found that plush animals increased the social interest and mental function of nursing home residents. In addition, plush animals produced a positive impact on self-concept and interaction and served as topics of conversation between the residents. The DAT patients studied by Bailey, Gilbert, and Herweyer 158 CLINICAL GERONTOLOGIST http://www.HaworthPress.com (1992) displayed increased alertness and social gestures along with diminished agitation when dolls and stuffed animals were present. Vickery (1998) asserted that an increasing number of “long term care facili- ties incorporate animal-assisted therapy into their package of services” (p. 93). Animals were originally introduced into nursing homes due to evidence of ani- mal interactions lowering blood pressure, releasing strain and tension, reliev- ing loneliness and depression, and increasing life expectancy (Farkas, 1997). They have also been used to “reach” individuals who lack interactional skills (Churchill et al., 1999). However, the effects of animal interactions go far be- yond these findings. Several studies investigated the effects of live animals on elderly individu- als (Churchill et al., 1999; Curtright & Turner, 2000; Erickson, 1985; Fick, 1993; Hopper et al., 1998; Kogan, 2000; Kongable, Buckwalter, & Stolley, 1989; Kongable, Stolley, and Buckwalter; 1990; Zisselman, Rovner, Shmuely, & Ferrie, 1996). Zisselman et al. (1996) investigated the differences between one group of elderly psychiatric patients receiving pet therapy and another receiv- ing exercise intervention. In the group receiving pet therapy, the subjects had contact with dogs and fed them. They were also encouraged to reminisce about dogs and other animals. Measurement consisted of a 40-item scale that ob- served the patients’ self-care functioning, disoriented behavior, depressed or anxious mood, irritable behavior, and withdrawn behavior. Both types of inter- vention yielded improved scores in the areas of self-care functioning, irritabil- ity, and withdrawal. Kongable et al. (1989) researched the effects of a pet dog on the social be- haviors among DAT patients in a veterans home. The twelve subjects were ob- served on the social behaviors of smiles, laughs, looks, leans, touches, verbalizations, name-calling, etc. The observations took place in three condi- tions (i.e., absence of the dog, temporary presence of the dog, and permanent placement of the dog) both in group and individual settings. Both the tempo- rary presence and permanent placement conditions led to an increased total number of social behaviors. Kongable et al. (1990) noted that pet therapy re- sults in social benefits, such as stimulation of interpersonal interactions. Churchill et al. (1999) found that the presence of a therapy dog “improved socialization and decreased agitation in persons with . . . [DAT] . . . during sun- down hours” (p. 21). Specifically, this study found that subjects produced twice as many verbal initiations when the dog was present. This study is simi- lar to Batson, McCabe, Baun, and Wilson (1998, as cited in Wilson & Turner, 1998), which showed that the presence of a therapy dog enhanced socialization behaviors of persons with DAT. Erickson (1985) stated that pets can serve as “social ice breakers” (p. 93). Animals have been shown to enhance interaction among residents, as well as Greer et al. 159 between staff and residents (Cusak, 1988; Erickson, 1985; Fick, 1993; Twiname, 1984). Price (1996) stated, “When a dog is taken in, it not only sparks conver- sation between the volunteer and the patient, but also among other residents” (p. 12). Fick (1993) examined the verbal behaviors of nursing home residents. She found that verbal interactions between subjects doubled in the presence of a dog. According to Savinsky (1985, as cited in Kogan, 2000), animals can serve as a topic of mutual interest to promote conversation. Furthermore, an animal can be used to stimulate verbalization of memories (Churchill et al., 1999). Curtright and Turner (2000) examined the effects of the presence of stuffed and live cats on the verbal communication of an elderly individual with DAT. The authors found that average meaningful communication increased during both conditions. They concluded that the total number of utterances in both the stuffed and live cat sessions was greater than that of baseline and withdrawal sessions. Live cats resulted in more meaningful communication than stuffed cats for their subject. Curtright and Turner indicated a need for replication of this study with a greater number of participants. Kongable et al. (1990) commented that patients with DAT are “at particular risk for social isolation and withdrawal because of their physiological and cog- nitive deterioration” (p. 17). Despite their deterioration, individuals with this debilitating condition continue to require, and more importantly, are able to engage in selected forms of socialization (Kongable et al., 1990). These stud- ies support the hypothesis that animals have a positive influence on the verbal and non-verbal communication of persons with DAT. Lubinski (1991) commented that persons with DAT do not tend to respond to direct treatment interventions for communication difficulties. More indirect treatments that are designed to facilitate automatic communication would be more beneficial. The purpose of this study was to examine the effects of toy and live cats on the verbal communication of individuals with DAT within a group setting. The present study was designed to expand on the earlier findings of Curtright and Turner (2000). METHODOLOGY Participants Six females qualified for participation in this study by meeting the follow- ing criteria: 1. spoke English as a first language, 2. had no reported history of depression, 3. were classified as having a moderate level of dementia based on Mini Mental Status Examination (MMSE) (Folstein, Folstein, & McHugh, 160 CLINICAL GERONTOLOGIST 1975) and the Functional Assessment Tool for Alzheimer’s-Type De- mentia (FAST) (Reisberg, Ferris, & Franssen, 1985). The six participants were randomly assigned to one of two groups. The sub- jects’ family members and/or legal guardians were contacted by the nursing home staff for permission to participate in this study. Informed consents were obtained for each participant. Methods An ABACA withdrawal design with counterbalancing across groups was implemented to assess verbal interactions of the participants. The subjects were placed in a family room, and their verbal communication was quantified in terms of total words, number of meaningful information units (MIU), and number of initiations in the presence and absence of live and toy cats. Baseline/withdrawal phases. Each baseline and withdrawal phase consisted of three 10-minute sessions. The subjects’ verbal communication was assessed in terms of total number of words, MIU, and initiations without a live or toy cat present. The participants were positioned around a card table facing each other. The examiner sat approximately two feet away from the group and operated a video camera. In addition, an audiocassette recorder was placed in the room for back-up recording purposes. The examiner remained a passive communicator throughout the interaction and only briefly responded when addressed during conversation. The exam- iner did not initiate conversation. After each session, the examiner scored the verbal communication components for each participant from the video tape re- cording (see sample recording form in Appendix A). Intervention phases. In one intervention phase of the study, two toy cats were placed on the table in front of the participants. This intervention phase consisted of three ten-minute sessions. Number of total words, MIU, and initi- ations were measured as they were in the baseline phase. The participants were again positioned around a card table with the examiner approximately two feet away. The same recording procedures were utilized. In the second intervention phase of the study, two live cats were placed on the table in front of the participants. This intervention phase consisted of three ten-minute sessions. Number of total words, MIU, and initiations were mea- sured as they were in the baseline phase. The participants were again posi- tioned around a card table with the examiner seated approximately two feet away. The same recording procedures were utilized. In addition, the examiner was responsible for keeping the cats within close proximity of the group. Greer et al. 161 The two intervention phases were counterbalanced between the groups to reduce the likelihood of sequencing effects. After initial baseline, Group 1 re- ceived the toy cat intervention phase. Group 1 then received the first with- drawal phase followed by the live cat intervention phase and a second withdrawal phase, yielding an ABACA series. The treatment phases were re- versed for Group 2 (ACABA). Stimuli As previously stated, the stimuli consisted of two toy cats and two live cats. The toy cats were purchased from a local toy store prior to the study and were unfamiliar to the participants. The live cats were also unfamiliar to the partici- pants. Data Collection The effect of the stimuli on the participants’ verbal communication was documented by counting the total number of words, MIU, and verbal initia- tions. Total words were defined as the total number of words produced during each 10-minute session. Repetitions within an utterance, unintelligible words and neologisms were not included. MIU were defined as words or phrases produced by the participant that had meaning, were not redundant, and were directly related to the conversation. Pronouns were not counted separately; however, specific sentence subjects, such as “farmer,” were. Specific adjectives were counted separately (e.g., green, beautiful). Nonspecific adjectives, such as, “very” or “really,” were not. Because negatives change the meaning of a sentence, they were also counted separately. Unintelligible utterances and neologisms were not in- cluded. By way of illustration, each of the following utterances contain three MIU: I don’t mean to be nosey. 1. do mean, 2. not, 3. nosey Funny jokes make me laugh. 1. funny, 2. jokes, 3. make me laugh Initiations were defined as utterances produced without a verbal model. They were counted if they introduced new information, and were directed to- wards another person or one of the stimuli. 162 CLINICAL GERONTOLOGIST Interscorer Reliability One session from each baseline, treatment and withdrawal phase was ran- domly selected for measuring reliability. An examiner who was not present for that particular session scored the verbal communication components. The number of point-to-point agreements was counted and divided by the total number of possible agreements (Hopper et al., 1998). Interscorer reliability was .88 for MIU, .97 for total words, and .99 for initiations. RESULTS Subject demographics and assessment results are listed in Table 1. The original methodology called for ten-minute sessions; however, not all subjects remained for the entire length of every session. Therefore, data were calcu- lated per minute rather than per session and are reflected as such. Graphs chart- ing individual performance for each session can be found in Appendix B. The pre-test baseline phase data were gathered over five sessions instead of three in an attempt to stabilize performance. However, lack of cooperation led to four baseline sessions for Group 1 and three baseline sessions for Group 2. The re- maining treatment and withdrawal phases consisted of three sessions each for both groups. Total Words In the toy cat condition, average subject performance for total words gradu- ally decreased across baseline (21.1/min), toy cat intervention (19.3/min), and subsequent withdrawal (16.4/min). When the live cats were present, average total words (24.8/min) increased from baseline (21.1/min), and continued to increase upon withdrawal (28.2/min) (see Figure 1). Average total words were greater during the live cat intervention than in the toy cat intervention. Greer et al. 163 TABLE 1. Subjects’ Demographics and Assessment Results Subject Age MMSE FAST Group 1 DF HR CM 90 88 87 15 19 7 6d 4 6c Group 2 AW BH EC 89 89 84 16 21 12 6d 5 6d Analysis of individual groups showed that Group 1 reverted to baseline af- ter an increase in the presence of toy cats. This group showed a continual in- crease in the presence and withdrawal of live cats (see Figure 2). Conversely, Group 2 showed a slight increase upon withdrawal of toy cats. These scores re- verted to baseline after an increase in the presence of live cats (see Figure 3). Meaningful Information Units In the toy cat condition, average subject performance for MIU was rela- tively stable during baseline (5/min), toy cat intervention (4.7/min), and subse- quent withdrawal (4.8/min) (see Figure 4). In the presence of live cats, average MIU (6.2/min) increased from baseline (5/min) and showed a slight decrease upon withdrawal (5.8/min). Overall subject performance showed greater num- ber of MIU when the live cats were present. Analysis of individual groups revealed that Group 1 increased production of MIU in the presence of toy cats and reverted to baseline upon withdrawal. In the presence of live cats, Group 1 increased from baseline and continued to in- crease when the cats were removed (see Figure 5). Group 2’s production of MIU decreased when the toy cats were introduced and increased upon with- drawal. In the live cat condition, Group 2 demonstrated an increase in MIU and a decrease upon stimuli withdrawal (see Figure 6). Initiations In the toy cat condition, average subject performance for initiations in- creased slightly (from 1.8/min to 2.1/min) and remained stable following with- 164 CLINICAL GERONTOLOGIST Average Total Words N u m b e r p e r M in u te Live cats Toy cats Phase Baseline Treatment Withdrawal 0 5 10 15 20 25 30 35 FIGURE 1. Average Total Words Across Both Groups drawal (2.1/min) (see Figure 7). On the other hand, in the presence of live cats, average initiations (2.5/min) increased from baseline (1.8/min) and decreased during withdrawal (1.7/min). Average initiations were greater during the live cat intervention than in the toy cat intervention. Analysis of individual groups revealed that Group 1 showed an increase from baseline in the presence of toy cats and reversed to baseline following withdrawal. Group 1 showed an increase in the presence of live cats and de- creased upon the stimuli withdrawal (see Figure 8). Group 2 demonstrated an increase in initiations when the toy cats were present and continued to increase upon their withdrawal. In the presence of live cats, Group 2 showed a similar performance to that of Group 1 (see Figure 9). Greer et al. 165 Average Total Words–Group 1 Toy Cats Live Cats Phase WithdrawalTreatmentBaseline N u m b e r p e r M in u te 35 30 25 20 15 10 5 0 FIGURE 2. Average Total Words for Group 1 Average Total Words–Group 2 N u m b e r p e r M in u te Phase Toy Cats Live Cats WithdrawalTreatmentBaseline 0 5 10 15 20 25 30 35 FIGURE 3. Average Total Words for Group 2 DISCUSSION The results indicated that live cats had the greatest influence on overall av- erage subject performance across all three measurements. Closer inspection of individual group performance showed that the live cats had a stronger effect on Group 2 than on Group 1. This is likely due to the fact that live cats were the first intervention for Group 2 and the second intervention for Group 1. This may be due to the subjects’ progressive loss of interest as the study went on. Several subjects voiced their refusal to come to or remain in the sessions dur- ing the later weeks of the study. 166 CLINICAL GERONTOLOGIST Average Meaningful Information Units Group 1 N u m b e r p e r M in u te Phase Toy Cats Live Cats 0 1 2 3 4 5 6 7 Baseline Treatment Withdrawal FIGURE 5. Average Meaningful Information Units for Group 1 Average Meaningful Information Units Live cats Toy cats Phase Baseline Treatment Withdrawal N u m b e r p e r M in u te 0 1 2 3 4 5 6 7 FIGURE 4. Average Meaningful Information Units Across Both Groups In the toy cat condition, the average performance of total words, MIU, and initiations was relatively stable across phases (baseline, treatment, and with- drawal). These findings are similar to those of Hopper et al. (1998), who found that the presence of toy stimuli did not influence the number of total words or verbal initiations for three of their four subjects. However, Hopper et al. also found that the presence of toy stimuli resulted in a greater number of meaning- ful statements from all of their subjects. Differences in the results between the Greer et al. 167 Average Meaningful Information Units Group 2 N u m b e r p e r M in u te Phase Toy Cats Live Cats Baseline Treatment Withdrawal 9 8 7 6 5 4 3 2 1 0 FIGURE 6. Average Meaningful Information Units for Group 2 Average Initiations N u m b e r p e r M in u te Phase Live cats Toy cats WithdrawalTreatmentBaseline 0 0.5 1 1.5 2 2.5 3 FIGURE 7. Average Initiations Across Both Groups two studies may be due to variations in methodology (e.g., Hopper et al. al- lowed examiner initiations and one-on-one sessions). Curtright and Turner (2000) also studied the influence of a toy cat on the verbal communication of an elderly individual with DAT. They found that the presence of a toy cat increased the number of complete information units and total number of utterances. The results of the present study are not equivalent to those of Curtright and Turner. The present study found that toy cats led to a slight decrease in total words and meaningful information units. This may be due to the inclusion of six subjects in the present study compared to only one subject in that of Curtright and Turner. In addition, Curtright and Turner al- lowed examiner initiation whereas the current study did not. However, inspec- 168 CLINICAL GERONTOLOGIST Average Initiations–Group 1 N u m b e r p e r M in u te Phase Toy Cats Live Cats WithdrawalTreatmentBaseline 0 0.5 1 1.5 2 2.5 3 FIGURE 8. Average Initiations for Group 1 Average Initiations–Group 2 N u m b e r p e r M in u te Phase Toy Cats Live Cats 3.5 3 2.5 2 1.5 1 0.5 0 WithdrawalTreatmentBaseline FIGURE 9. Average Initiations for Group 2 tion of individual performances in the present study showed that toy cats appear to have positively influenced CM’s production of total words and MIU (see Appendix B). That particular subject’s performance is comparable to the findings of Curtright and Turner. In the live cat condition, the average production of total words, MIU, and initiations increased compared to baseline. Upon withdrawal of the live cats, overall average total words continued to increase, overall average MIU slightly decreased, and overall average initiations decreased to baseline levels. The findings for the initiation variable are similar to those of Fick (1993), who found that the presence of a dog resulted in an increase in verbal interactions between subjects. Temporary placement of live animals produces a novel situ- ation that may elicit more verbal communication. The findings for the total words and MIU variables are comparable to those of Curtright and Turner (2000) who also studied the influence of a live cat on the verbal communication of a single elderly individual with DAT. They found that the presence of a live cat increased meaningful communication as well as total number of utterances. Upon analysis of individual performance in the present study, EC demonstrated the greatest benefit from the live cat interven- tion across total words and MIU (see Appendix B). EC and the subject exam- ined by Curtright and Turner were similar in MMSE score with 12 and 14, respectively. An interesting finding upon individual analysis was that CM and EC dem- onstrated a favorable response to the toy cats and the live cats, respectively. These two subjects had the lowest MMSE scores and two of the most severe FAST scores (see Table 1). Hopper et al. (1998) found increased verbal com- munication in patients with MMSE scores ranging from 8 to 12 in response to toy stimuli. CM, whose MMSE was 7, showed greater verbal communication in the presence of toy cats. Curtright and Turner’s (2000) subject, who re- sponded more favorably to a live cat, scored a 14 on the MMSE. EC, whose MMSE was 12, performed similarly. These results may indicate that therapy involving toy and live cats would be most effective for more severely impaired individuals with DAT. This indicates they may need more external stimuli to promote conversation. Future research may want to consider focusing on more severe individuals. Still, this individual variability in the results point to the need for future research to focus on more precise candidacy issues for these types of therapeutic approaches. The findings of the present study demonstrate that the live cats, overall, re- sulted in greater number of total words, MIU, and initiations than the toy cats. Curtright and Turner (2000) found that the live cat resulted in more meaning- ful communication than the toy cat, but no difference was found in the measure of total number of utterances. The results of the present study showed that the Greer et al. 169 live cats encouraged interaction between the subjects and the stimuli. That is, the subjects talked to and touched the live cats more than they did the toy cats. This is similar to the performance of the subject examined by Curtright and Turner. Live cats initiate by approaching and touching people. It was noted that the subjects often communicated to the examiners and the stimuli. Although the examiners remained passive communicators and sat apart from the group, subjects would often initiate communication with them rather than with the other subjects. The subjects also spoke directly to and touched the live cats, which is similar to that found in Curtright and Turner (2000). However, unlike Curtright and Turner, the subjects occasionally spoke to and touched the toy cats. Additionally, their number of initiations was significantly greater than their number of responses, which indicates that the subjects were not talking to each other. However, the subjects initiated and responded during conversations with the examiners outside of the assessment room. Their utterances tended to be appropriate, meaningful, and social. It appears that when examiners directly addressed the subjects, they tended to participate in conversation. This was not evident during the formal testing sessions, due to the subjects’ tendency not to address each other. In contradistinction, Hopper et al. (1998) found that their subjects interacted more effectively. However, the more encouraging results in their study could be attributed to the use of examiner initiations in conjunction with their toy stimuli. These findings suggest that subjects may perform better when topics are initiated by a communicative partner. To examine the more so- cial aspects of communication, researchers should consider focusing their mea- surement on the quality of communicative exchanges between subjects rather than isolated measures of quantity, such as number of initiations. Other characteristics may have affected the subjects’ performance. For ex- ample, EC’s harsh voice quality made her unintelligible at times and BH dem- onstrated a difficulty hearing as she frequently asked for clarification and responded inappropriately. These variables could be included within the ex- clusion criteria of future studies. Furthermore, DF and BH both exhibited con- fusion during sessions. A better screening for research subjects could also minimize this confounding variable. Finally, subjects would lose interest and even doze off during recorded sessions. This could be prevented by a more ac- tive participation of the investigator. Future research should take these factors into consideration as well as incorporating both genders and more subjects. CONCLUSION This study proposed to look at the effects of toy cats versus live cats on the verbal communication of elderly females with DAT. Overall, live cats were 170 CLINICAL GERONTOLOGIST found to have a greater influence on subject performance than toy cats, due to their active nature, which could be interpreted as communicative initiations. Analysis of individual group performance showed that each group responded more favorably to their first intervention phase. Observations of communica- tion outside the study, as well as findings from the literature, suggest that indi- viduals with DAT may increase meaningful communication when active communicative partners are present. REFERENCES Bailey, J., Gilbert, E., & Herweyer, S. (1992). To find a soul. Nursing, 22, 63-64. Bayles, K. A. & Kasniak, A. W. (1987). Communication and cognition in normal aging & dementia. Boston: College-Hill Press, Little, Brown, & Company. Bellenir, K. (1999). Alzheimer’s disease sourcebook, (2nd ed.) Detroit: Omnigraphics. Churchill, M., Safoui, J., McCabe, B. W., & Baun, M. M. (1999). 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The American Journal of Occupa- tional Therapy, 50, 47-51. 172 CLINICAL GERONTOLOGIST A P P E N D IX A S u b je ct 1 T W M IU I S u b je ct 2 T W M IU I S u b je ct 3 T W M IU I E xa m in e r T W I 173 174 CLINICAL GERONTOLOGIST Total Words–D.F. (Group 1) T o ta l W o rd s p e r M in u te Session A1 A2 A3 A4 A5 B1 B2 B3 A6 A7 A8 C1 C2 C3 A9 A10 A11 Total Words–H.R. (Group 1) T o ta l W o rd s p e r M in u te Session A1 A2 A3 A4 A5 B1 B2 B3 A6 A7 A8 C1 C2 C3 A9 A10 A11 0 5 10 15 20 25 30 35 45 50 55 60 65 70 75 80 85 90 90 85 80 75 70 40 0 5 10 65 60 15 20 55 50 25 45 30 40 35 APPENDIX B Greer et al. 175 Total Words–C.M. (Group 1) T o ta l W o rd s p e r M in u te T o ta l W o rd s p e r M in u te Session Session Total Words–A.W. (Group 2) A1 A2 A3 A4 A5 B1 B2 B3 A6 A7 A8 C1 C2 C3 A9 A10 A11 0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 0 90 85 5 10 15 20 30 35 40 45 50 55 60 65 70 75 80 A1 A2 A3 A4 A5 C1 C2 C3 A6 A7 A8 B1 B2 B3 A9 A10 A11 25 176 CLINICAL GERONTOLOGIST 0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 Total Words–B.H. (Group 2) T o ta l W o rd s p e r M in u te Session A1 A2 A3 A4 A5 C1 C2 C3 A6 A7 A8 B1 B2 B3 A9 A10 A11 Total Words–E.C. (Group 2) 0 5 10 15 25 30 35 40 50 55 65 70 75 80 85 90 Session A1 A2 A3 A4 A5 C1 C2 C3 A6 A7 A8 B1 B2 B3 A9 A10 A11 T o ta l W o rd s p e r M in u te 60 45 20 APPENDIX B (continued) Greer et al. 177 Meaningful Information Units–D.F. (Group 1) M IU p e r M in u te A1 A2 A3 A4 A5 B1 B2 B3 A6 A7 A8 C1 C2 C3 A9 A10 A11 Session 0 2 4 6 8 10 12 14 16 16 14 12 10 8 6 4 2 0 M IU p e r M in u te Session A11A10A9C3C2C1A8A7A6B3B2B1A5A4A3A2A1 Meaningful Information Units–H.R. (Group 1) 178 CLINICAL GERONTOLOGIST 16 16 14 14 12 12 10 10 8 8 6 6 4 4 2 2 0 0 A1 A1 A2 A2 A3 A3 A4 A4 A5 A5 B1 B1 B2 B2 B3 B3 A6 A6 A7 A7 A8 A8 C1 C1 C2 C2 C3 C3 A9 A9 A10 A10 A11 A11 Session Session 18 M IU p e r M in u te M IU p e r M in u te Meaningful Information Units–A.W. (Group 2) Meaningful Information Units–C.M. (Group 1) APPENDIX B (continued) Greer et al. 179 A1 A1 A2 A2 A3 A3 A4 A5 A5A4 C1 C1 C2 C2 C3 C3 A6 A6 A7 A7 A8 A8 B1 B1 B2 B2 B3 B3 A9 A9 A10 A10 A11 A11 Session Session 18 18 16 16 14 14 12 12 10 10 8 8 6 6 4 4 2 2 0 0 M IU p e r M in u te M IU p e r M in u te Meaningful Information Units–B.H. (Group 2) Meaningful Information Units–E.C. (Group 2) 180 CLINICAL GERONTOLOGIST A1 A2 A3 A4 A5 B1 B2 B3 A6 A7 A8 C1 C2 C3 A9 A10 A11 Session 0 1 2 3 4 5 6 7 8 9 In it ia ti o n s p e r M in u te In it ia ti o n s p e r M in u te Session Initiations–D.F. (Group 1) Initiations–H.R. (Group 1) 9 8 7 6 5 4 3 2 1 0 A1 A2 A3 A4 A5 B1 B2 B3 A6 A7 A8 C1 C2 C3 A9 A10 A11 APPENDIX B (continued) Greer et al. 181 9 9 8 8 7 7 6 6 5 5 4 4 3 3 2 2 1 1 0 0 A1 A1 A2 A2 A3 A3 A4 A4 A5 A5 B1 B1 B2 B2 B3 B3 A6 A7 A8 C1 C2 C3 A9 A10 A11 Session Session C1 C2 C3 A6 A7 A8 A9 A10 A11 Initiations–C.M. (Group 1) In it ia ti o n s p e r M in u te In it ia ti o n s p e r M in u te Initations–A.W. (Group 2) 182 CLINICAL GERONTOLOGIST Initiations–B.H. (Group 2) In it ia ti o n s p e r M in u te In it ia ti o n s p e r M in u te A1 A2 A3 A4 A5 C1 C2 C3 A6 A7 A8 B1 B2 B3 A9 A10 A11 Session 9 8 7 6 5 4 3 2 1 0 Initiations–E.C. (Group 2) 9 8 7 6 5 4 3 2 1 0 A1 A2 A3 A4 A5 C1 C2 C3 A6 A7 A8 B1 B2 B3 A9 A10 A11 Session APPENDIX B (continued)