Download Facilitating Communication in Individuals with Neurological Disease

Facilitating Communication
in Individuals with
Neurological Disease
Argye E. Hillis, MD, MA
Johns Hopkins University School
of Medicine
Stroke: Aphasia,
Apraxia of Speech &/or Dysarthria

Aphasia: Impaired language
– Symbolic communication
– Words, grammar
– Comprehension and/or production of language are
impaired
– Verbal and/or written communication (reading and/or
writing) are impaired
Apraxia of speech: motor planning and
programming of speech articulation
 Dysarthria: Impaired motor speech due to
weakness, impaired coordination, reduced rate
or range of movement of jaw, lips, tongue,
palate, vocal cords, respiratory muscles

Nonfluent (Broca’s) Aphasia
Telegraphic speech: content words
 Agrammatic
 Nouns named better than verbs
 Spoken and written sentence production are
impaired
 Poor spelling (especially verbs)
 Relatively good comprehension

– May have trouble with syntactically complex
sentences, passive voice sentences
Stroke: Nonfluent Aphasia

Facilitate comprehension
– Speak in short, complete sentences
– Simplify grammatical structure:
– Avoid passive voice
 Instead of: Linda was kicked by the boy.
 The boy kicked Linda.
– Avoid before/after, in front of/ behind
 Instead of: Please sign the form after you have
read it
 Please read the form. Then sign it.
Stroke: Nonfluent Aphasia

Facilitate verbal expression
– Provide choices for answers
– Instead of: What do you want for dinner?
– Do you want chicken, steak, or fish?
 Chicken? Steak? Fish?
 Or written choices
– If you think you know the possible word being
attempted, provide the first sound
 For fish, say /f/
– Or provide written words – may cue them to
say the word correctly
Stroke: Fluent (Wernicke) Aphasia
Fluent, jargon speech
 Well articulated; may be “empty”
 May use meaningless combination of
English words, or use “neologisms” (made
up words; e.g., splarinic)
 Often name verbs better than nouns
 Spoken and written production are impaired
 Poor comprehension of spoken and written
words

Stroke:
Fluent (Wernicke’s) Aphasia

Facilitate comprehension
– Provide gestures, pictures, context
– Speak in short, complete sentences
– Pause between sentences
– Avoid low familiarity words
– Rephrase sentences in a different way
 After “We will be going to the shopping center in a
few minutes”
 “We are leaving for the mall soon”
Stroke: Wernicke’s Aphasia

Facilitate expression
– If you don’t understand, say so apologetically
(& shake your head)
– Provide choices, with pictures/gestures
– Do you want:
 Chicken?
 Fish?
 Steak?
– Ask him/her to point, then say the word
– Encourage gestures, drawing, pointing
 Model their use for communication
Stroke: Wernicke’s Aphasia
Try a communication notebook with words
and pictures
 Organize by theme

– Family, pets, activities, places
Have him/her select items to include
 Model its use in communication
 Higher tech augmentative communication
devices require more training

Stroke: Anomic Aphasia

Anomia: “without names”
– Poor word finding
– Tip of the tongue phenomenon
– Nouns often disproportionately affected
– Produce circumlocutions (e.g., for fork: “the
thing you use to eat, to stab with, like for
vegetables)
– May produce paraphasias (word substitutions)
 Fork-> “cork” or “hork”
 Fort-> “spoon”
Stroke: Anomic Aphasia

Provide a communication notebook with
written words
– Pocket size is best
– Organize into “chapters” with themes
 People (friends, family, staff, famous people)
 Activities (responsibilities, hobbies, ADLs)
– Have him or her choose the items to include
– Add items frequently (leave room)
Model its use in communication
 The Visual Dictionary

Communication Notebook
Ex: Chapter on People
Separate pages for:
 Family

–
–
–
–
Mary, Karen, Betsy (sisters)
John (brother)
Dad, Mom, Grandma
Linda, Bob, Harry (cousins)
Neighbors, Friends, Colleagues
 Community: pastor, maid, barber, therapists,
doctors,
 Politicians, actors, actresses, atheletes

– Whatever they like to talk about
Apraxia of Speech
Impaired planning and programming of
speech articulation, that cannot be
explained by weakness, impaired
coordination, or reduced rate or range of
movements of the muscles of the jaw, lips,
palate, tongue, vocal cords
 Multiple, variable off-target attempts to
articulate a word
 Trouble with polysyllabic words
 Often associated with aphasia or dysarthria

Apraxia of Speech
Facilitate expression
 Have patience!
 Encourage them to write if necessary
 Keep paper and pencil handy
 Encourage them to try again or rephrase
with shorter words

Brainstem or Bilateral Stroke:
Dysarthria
Spastic dysarthria: slow, reduced range of
movement, harsh/strained voice quality
 Flaccid dysarthria: weak, breathy,
hypernasal
 Ataxia dysarthria: poor coordination of
muscles of jaw, lips, tongue, palate

– Inappropriate pitch changes, hyper/
hyponasality, slow to compensate
– Trouble with consonant blends (e.g, splash,
flasks)
Dysarthria: Facilitate expression
Ask them to rephrase, not just repeat, if
you don’t understand
 Ask them to speak slowly
 Ask them to point to the first letter of
each word on an alphabet board, or write
the first letter of each word, as they speak

– Slows them down
– Provides additional information

Communication notebook may help
Stroke: Right Hemisphere

Trouble with abstract language
– Metaphors
– Analogies
– Proverbs
– Jokes
Trouble understanding vocal intonation,
facial expression, gestures
 Limited intonation, facial expression,
gestures

Stroke: Right Hemisphere

Facilitate comprehension
– Avoid metaphor
 e.g., He kept her on a pedestal.
– Avoid sarcasm! (it may be taken literally)
– Convey meaning and emotion with words –
don’t rely on facial expressions & gestures

Facilitate expression
– Ask him or her to tell you his/her emotions
ALS: Lou Gherig’s Disease
Dysarthria: Mixed spastic and flaccid: Weakness
& reduced rate and range of movements of jaw,
lips, palate, tongue, vocal cords
 Often associated with emotional lability

– Laughter & crying out of proportion to emotion

Can be associated with frontotemporal
dementia: asymmetric atrophy of the frontal and
temporal lobes
ALS: Facilitate expression
Ask them to rephrase, not just repeat, if
you don’t understand
 Ask them to speak slowly
 Ask them to point to the first letter of
each word on an alphabet board, or write
the first letter of each word, as they speak
 Try occluding nose to reduce escape of air

– Palatal lift may help
Bulbar ALS or Brainstem Stroke
with Inability to Speak
Always provide paper & pencil or other
means to express nonverbally
 Consider “augmentative communication”

– Low tech:
 Communication notebook: words/phrases
 Alphabet board: May be plexiglass/transparent to
allow them to select letters with eyes, in such a
way that “listener” can detect their selection
Augmentative Communication: High Tech
Laptop computer systems or devoted systems
for communication
 Variety of inputs to the computer

– May rely on just eye movements, sip/puff, joy stick,
any reliable movement
– Row/column scanning, morse code, direct selection
(best)

Output:
– Print (good for permanent record)
– Verbal (important for phone, audiences)
 stored words/phrases, synthesized/digitized speech
 Pizza – Peetsa
Multiple Sclerosis: MS

Dysarthria: mixed ataxic and spastic
– Ataxic: Poor coordination of the jaw, lips,
palate, tongue
– Spastic: slow, reduced range of movement
May be associated with cognitive and/or
emotional problems
 Often associated with ataxia (poor
coordination) of the limbs

MS
Facilitate expression: Same methods for
other causes of dysarthria
 May need to weight ataxic limb with other
limb to point or type
 May take extra time to learn new system
 Show patience, desire to understand

Dementia

Alzheimer’s Disease
– Progressive decline in memory
– Progressive decline in at least one other domain of
communication
Vascular Dementia (due to strokes)
 Frontotemporal Lobar Degeneration

– Dysexecutive syndrome (right frontal or temporal)
– Progressive, Nonfluent aphasia – left frontal form
– Semantic Dementia – left temporal form
Dementia

Facilitate comprehension
– Speak in short, complete sentences
– Repeat frequently
– Write in short, complete sentences
 Reminders regarding where loved ones are & when
they will return, what they need to do (e.g., take
medications – specify what and when)
 Make copies, put them everywhere
– Use familiar, high frequency words
– Avoid abstract language
– Use gestures, drawings, pictures if needed
Dementia

Facilitate production
– Ask open-ended questions
– Show patience when they speak
– Communication notebook, especially with
names of people, places, and events may help
them recall words they want to use
– Include calendar, mark off days as they go by,
mark future events, appointments (yours and
theirs), responsibilities (e.g. take out trash)