chapter 20 Managing speech and language deficits after stroke
After completing this chapter, the reader will be able to accomplish the following:
1. Understand the impact of communication impairment following stroke.
2. Be aware of the incidence and prevalence of communication disorders.
3. Understand the various types of communication problems following stroke.
4. Understand the presentation and management of various communication disorders.
Communication disorders have a devastating effect not only on the rehabilitative process, but on the overall quality of life of the stroke survivor.35,50 The objectives of this chapter are, first, to inform the occupational therapist and others regarding communication disorders found in stroke to increase the effectiveness of their intervention and, second, to discuss the ways in which the speech-language pathologist and occupational therapist can work collaboratively to foster better outcomes in the survivor’s life participation. The chapter begins with a discussion about communication in general, and is followed by a description of the nature and the range of communication problems associated with stroke and the incidence and prevalence of communication disorders. Some guidelines provided may be helpful for the occupational therapist in enhancing communication with patients following stroke.
Scope of communication
Communication is simply the transfer of information from one individual to another.12,22,35 Human communication in all of its many forms fits within this definition, but for members of a human community, communication in all of its forms has much more meaning.17,64 Humans’ individual personality is displayed in their style of communication. They use gestures, facial expression, and vocal emphasis to convey more than facts. Their various modes of communication signify engagement and intention in their interaction with others. In addition, they communicate differently at home than they do in negotiating the tasks of daily life in the community. Furthermore,* their social interactions with their friends require different communicative skills than those required in most work settings.
The intricacy of human communication is compounded by the range and variety of skills with which they communicate.64 Society’s emphasis on communication has expanded with advances in communication technology. To be a successful communicator, one must not only be able to speak and comprehend spoken messages, but also understand and produce written and electronically transmitted information.8 One cannot view communication in a vacuum of merely sender and receiver.31 Cultural values, not only those associated with different languages and ethnic groups but with each life setting, have their own rules of interaction, which are internalized by the communication partners.21,44,67,76
Impact of communication impairment following stroke
The reaction of the stroke survivor to communication impairment is unique to the individual. The very suddenness of a stroke may overwhelm one’s sense of well-being.94 The alteration of communication in the first few days and weeks following the “brain attack” results in a range of emotions, from sheer terror in some individuals to indifference in those with little awareness of their deficits.63,66 These responses depend on a variety of factors, including the locus and extent of the lesion, the nature of the deficits, the accompanying medical and physical problems, and the individual’s personality characteristics.68 In addition, the premorbid abilities of persons with communication disorders vary across the continuum, from those whose livelihood and identity are defined by speaking several languages, writing books, and/or giving speeches to those whose identity is based on activities other than spoken language.27,68 Many stroke survivors describe issues of loneliness, social isolation, loss of independence/privacy, restricted activities, loss of work/income, and social stigmatization.94,95 Sarno95 has stated that the loss of communication in aphasia, for example, is a loss of personhood or of personal identity. For some, these changes in communication alter one’s roles in life and influence one’s sense of personal identity.27,68,94 These reactions and the reactions of friends and family are crucial considerations in the overall management plan.
Families of persons with communication impairment following stroke are more prone to difficulties in psychosocial adaptation than those with similar physical changes but intact communication.27,35 Although family members’ responses are individual and wide-ranging, their coping patterns are established prior to the onset of stroke and are found to be rather stable.27,35,104 A greater than normal burden is placed on the caregiver when individuals require significant assistance in expressing themselves.27,35,52
Living successfully with communication impairments requires adaptations in life and consciously making choices.27,35,104 These qualities are embedded in the person’s personality and also in the coping strategies of the patient’s significant others. Qualities of resilience in the face of challenges include the ability to maintain a distinct sense of self throughout the recovery process and not allowing for the development of overdependency.53,70 Having a caregiver that can be flexible in changing roles, both in assuming the role of caregiver and relinquishing the role when appropriate, facilitates successful adaptation. Staying engaged in life helps one avoid boredom and depression.70,104 Understanding that one can be valued and participate in life even with significant communication impairment is essential.35,71,104 Openness to venturing out and having fun or pursuing something new is also a characteristic of those who live successfully following stroke.70,104
Cultural responses are relevant to the patient’s willingness to participate in rehabilitation. The stroke survivor has internalized the values of his or her society for speech and communication function.94 When communication disorders are identified, the survivor may fear that he or she is mentally challenged.68 Family and friends hold similar cultural values and, as the closest group to the patient, may reinforce the sense of incompetence by making rehabilitation decisions without the survivor’s input and unwittingly adding to the shame and embarrassment.35,68 The fact that it is difficult to overcome and address these cultural biases argues for education of various types in multiple languages.15,108 The need for current information in many languages about stroke is increasing with the steady expansion of the multilingual population.15 Furthermore, access to medical care, to social settings, and to vocational options is constrained by the interaction of social, cultural, and linguistic factors.15 Grassroots organizations, such as the National Stroke Association, American Stroke Association,4 and Aphasia Association, are attempting to modify these misconceptions about stroke and communication disorders. In addition, the National Aphasia Association86 is confronting the stigmatization that society gives to individuals who exhibit an obvious speech problem through raising awareness and by providing education in many languages.86
Incidence and prevalence of communication disorders
Valid statistical information about the incidence of speech and language disorders following stroke is not available. However, according to the American Heart Association,3 in 2006 there were around 6.5 million stroke survivors alive, and “on average, every 40 seconds someone in the United States has a stroke.”3 The percentage of strokes that have the initial symptom of speech and/or language issues is unknown. Around 25% to 40% of acute strokes result in aphasia, according to the National Aphasia Association.86 However, the presence of aphasia may not be the most common communication symptom following stroke. The incidence and prevalence of dysarthria and cognitive communicative impairment following stroke are unavailable and may be more common and debilitating than aphasia.33
It is almost impossible to quantify the percentage of persons with communication problems. Included in the well-publicized “stroke warning signs” is the presence of changes in speech.4 Medical records of hospital admissions for stroke often include patient complaints of “slurred speech.” Many of these initial speech symptoms disappear shortly after, but other subtle changes in communication may be undetected by both the patient and health care professionals.77 This lack of concern is understandable in the initial stages, since the focus is on acute medical treatment, preserving life, and intervening to preserve brain function, thus mitigating possible long-term disability.79 Consequently, the less obvious changes in cognitive communicative function are not of paramount concern. The reduced hospital stay for patients with stroke, and the shortened admission to acute and subacute rehabilitation results in limited access to treatment, and under the best of current practices, this leaves many patients either unidentified or undertreated.56
The types of communication problems found in stroke
Stroke results in three general categories of communication disorders: dysarthria, aphasia, and cognitive communicative impairment.28,33 Each type of disorder is associated with a particular site of the damage in the peripheral and central nervous system. Although these three types can and do occur together, they will be discussed as separate categories.
1. Dysarthria is “a collective name for a group of neurologic speech disorders resulting from abnormalities in the strength, speed, range steadiness, tone, or accuracy of movements required for control of the respiratory, resonatory, articulatory, and prosodic aspects of speech production. The reasonable pathophysiologic disturbances are due to central or peripheral nervous system abnormalities and most often reflect weakness; spasticity; incoordination; involuntary movements; or excessive, reduced, or variable muscle tone.”33
2. Aphasia is an acquired communication disorder caused by brain damage, characterized by an impairment of language modalities: speaking, listening, reading, and writing; it is not the result of a sensory or motor deficit, a general intellectual deficit, confusion, or a psychiatric disorder.47
3. Cognitive-communication disorders encompass difficulty with any aspect of communication affected by disruption of cognition. Communication may be verbal or nonverbal and includes listening, speaking, gesturing, reading, and writing in all domains of language (phonological, morphological, syntactic, semantic, and pragmatic). Cognition includes cognitive processes and systems (e.g., attention, perception, memory, organization, executive function). Areas of function affected by cognitive impairments include behavioral self-regulation, social interaction, activities of daily living, learning and academic performance, and vocational performance.110
The role of the speech-language pathologist across the continuum of care
The field of speech-language pathology has a relatively long history of investigating, defining, and treating communication disorders. However, the treatment of stroke-related communication disorders by speech-language pathology is relatively recent and grew out of a medical specialty in physical rehabilitation (physiatry).95 Physical rehabilitation as a specialty had its beginning after World War II.10,39,97 Prior to World War II, little attempt had been made to ameliorate debilitating conditions such as those following stroke. The experience of treating the war injured revealed the positive effects of physical treatment and pointed to the need for rehabilitation of similarly disabled individuals in the civilian population.10,39 The field of speech-language pathology, along with occupational therapy, physical therapy, psychology, and social work were seen as integral to the team approach, which characterized the new field of physiatry (Physical Medicine and Rehabilitation).20,42,97,111
The inclusion of speech-language pathology into the rehabilitation model greatly expanded its scope of practice. Most people now take for granted that the rehabilitation team is the optimal model for stroke management.20,111 The focus of rehabilitation medicine goes beyond other medical specialties in three ways: (1) its concern for the “whole” person rather than the illness or condition for which service was required, (2) the notion of “living with a condition” and “maximizing function” as opposed to curing chronic conditions, and (3) the inclusion of a psychosocial perspective that recognizes that the stroke happens not only to the survivor, but also to the family and friends.96 The hallmark of rehabilitation has been its focus on function, and the contribution of that model to speech-language pathology is to focus on functional communication.104,112
Currently, stroke management is spoken of in terms of a continuum of care and a multiple phase process. Stroke management begins in the emergency department with a focus on rapid medical treatment and extends to years poststroke as the survivor learns to live with chronic impairments.48,111 The speech-language pathologist may intervene at various points in this continuum. The settings include the emergency department, acute medical hospital stay, acute rehabilitation, home care, outpatient and long-term care, and community integration.56 In each of these settings, the role of the speech-language pathologist changes. Although in all settings they begin with an evaluation of motor control of the speech mechanism, an assessment of language function, and an analysis of cognitive factors affecting communication, the comprehensiveness of the evaluation and the focus of treatment or management varies.48,57 Rehabilitation services that facilitate the process of integration into the community and assumption of vocational/avocational endeavors are limited. While speech-language pathologists are focusing on “life participation” activities for individuals with aphasia,16 almost no attention is given to the process of integration for those with other communication disorders.
The management of communication disorders
Major dysarthrias associated with stroke
Normal speech production requires the exquisite coordination of a large number of muscle groups, which control respiration, phonation (voice production), resonation, and articulation.28,31 The complexity of the control is due to established movement patterns that are unique to each language and are automatic. For example, the respiratory cycle is modified to have an increased duration during speech, and the vocal folds vibrate more quickly at the end of questions to raise the pitch.11 Conversational articulation involves approximately 500 different oral shapes per minute, and even a minor deviation in control patterns can influence the precision of speech production.31 Remarkably, the average speaker performs these actions automatically with no awareness or conscious planning.28 Any disturbance in the control of movements of respiration, phonation, resonation, and articulation may be reflected in speech, which is the primary modality of human communication.28 The resulting speech disorders that may emerge following stroke include unilateral upper motor neuron dysarthria, spastic dysarthria, anarthria, and ataxic dysarthria.33
Unilateral upper motor neuron dysarthria
One of the easiest speech pathologies to identify, and probably the most common speech disorder following stroke, is known as “unilateral upper motor neuron dysarthria,” which is relatively mild and often resolves in the weeks following stroke.33,35,38 This impairment in the precision of consonant articulation is due to unilateral changes in muscle tone and accompanying weakness of the muscles of the speech mechanism.33,38,82
The speech-language pathologist evaluates the impact of this disorder on intelligibility of speech and effectiveness of communication.82,114 Although unilateral upper motor neuron dysarthria may occur after either left or right hemisphere strokes, the specific abilities probed and assessment tools selected depend on the location of the stroke.33,38 When the dysarthria persists as part of the sequelae of right brain stroke, it involves not only the accuracy of articulation but also changes in voicing and delivery that include rate and inflection of speech.34,38,49,82 There is often an accompanying lack of facial affect. Sometimes these patients are somewhat hypoaroused and lethargic.32 These characteristics may influence the quality of communication almost as much as the motor speech disorder.33,38
There are many opportunities for collaboration between occupational therapy and speech-language pathology with patients who have right brain injured unilateral upper motor neuron dysarthria.42 Individuals with this dysarthria, though fairly intelligible, are often unaware of when they are not being understood.33,38 In partnership with the speech-language pathologist, the occupational therapist may provide feedback to patients and increase their awareness of the deviations in their speech output.42 Because many right brain injured patients are concrete in their interpretation of what is said to them, it is helpful for the feedback to be specific and concrete. For example, say, “I had difficulty understanding you because your voice was not loud enough” rather than simply requesting that the patient repeat what was said. For the individual with a right gaze preference and left neglect, reinforcement by all members of the team to look at the speaker when communicating may increase communication effectiveness. Given the change in awareness and reasoning, collaborative treatment and reinforcement of goals increases the transfer of learning.33,38 See Chapter 19.
Following a left stroke of the unilateral upper motor neuron pathways, aphasia (language disorder) may accompany the dysarthria.24,33 Without aphasia, the stroke survivor with left unilateral upper motor neuron dysarthria may function fully in life participation, even with persisting motor speech deficits, as long as speech is intelligible to the listener. Diagnosis of a concurrent language difficulty is sometimes obscured by the dysarthria and requires a comprehensive examination to identify subtle language changes.33,38 These language disorders are discussed later in this chapter. On the other hand, individuals with left hemisphere unilateral upper motor neuron dysarthria may appear to have a language disorder when none is present.33 They may speak less frequently, use shorter phrases, simplify sentences, but in fact not show any language dysfunction when formally assessed. These reductions in speech may simply reflect a motor speech disability rather than an underlying language problem.
Spastic dysarthria (bilateral upper motor neuron dysarthria)
The impact of bilateral upper motor lesion strokes on communication is substantial and is not simply the addition of the two upper motor neuron dysarthrias, but is a different speech disorder. Historically, this dysarthria is associated with the term “pseudobulbar palsy.”28,38 According to Darley and associates,28 there are four muscular abnormalities that affect function in pseudobulbar palsy: spasticity,* weakness, limited range of movement, and slowness of movement.
The patient with spastic dysarthria has a strained-strangulated hoarse (rough) low-pitched voice.28,33,38,82 He speaks slowly, with effort and extreme hypernasality and is monotonal in his delivery. Due to the absence of the sensitive coordination of timing of the onset of voicing, often his articulation of /p/ is said as a /b/, and similar confusions exist with /t - d/ and /k - g/.28 These deviations in speech affect intelligibility and efficiency of communication. Individuals with spastic dysarthria tend to speak rarely, not because they are necessarily aphasic, but because of the effort that is required to speak. In addition, these patients manifest a flat affect but also display emotional outbursts in the form of emotional lability.33,38 Speaking of even mildly emotional topics may trigger laughing or crying in inappropriate contexts. This lability is known as “pseudobulbar affect.”28,38 The location of the brain damage determines whether language function is spared or affected. Because of bilateral damage, these patients may have considerable upper extremity limitations affecting their ability to gesture, write, and use a computer.28
There are some general guidelines to follow when working with individuals with spastic dysarthria:28,33,72 (1) acknowledge the effort needed to speak by providing extra time for the speech process; (2) validate (confirm) that the message was understood by repeating back what was said and thus give the patients a sense of control by confirming that they have been understood; (3) recognize that increasing spasticity in one part of the body (e.g., the upper extremity) may result in increased stiffness in the speech mechanism, and therefore do not expect speech during activities that increase spasticity; and (4) remind patients that the emotional lability is not within their control. Sometimes therapists have provided a notice to listeners that the patient’s crying does not necessarily mean that he or she is sad, but that crying “just happens.” Occupational therapists can assist the patient’s recovery of Communication effectiveness by addressing team goals that target the previous behaviors.42
Anarthria and locked-in syndrome (brainstem and bilateral midbrain lesions)
In order to provide appropriate care to individuals without speech, differential diagnosis must distinguish among anarthria, locked-in syndrome, and mutism.26,28,33,85 Anarthria is the absence of speech due to severe motor speech impairment.33 Duffy reported that this condition is different from mutism, which is due to a cognitive dysfunction limiting the production of speech.33 When the profound impairment of speech is accompanied by immobility of the body except for vertical eye movements, the disorder is called locked-in syndrome. Duffy described locked-in syndrome as a “special and dramatic manifestation of anarthria.”33 Intact language generation is often demonstrated once a communicative system is established. In his personal account, The Diving Bell and the Butterfly, Jean-Dominique Bauby7 described blinking to indicate letters of the alphabet as the communication partner spoke the letters. When working with individuals without speech, the speech-language pathologist must determine the presence or absence of cognitive/linguistic function.
Medical treatment for locked-in syndrome has changed significantly over time.85 Individuals with this rare condition have a better long-term survival rate than in the past.33 Those who survive over many months require intensive rehabilitation to maximize their function. Establishing a basic communication system of “yes” and “no” is the first step and may be based on an eye blink system.65 Once this is established, one can move on to more elaborate communication systems including letter boards and electronic systems. The painstaking effort described by Bauby is greatly reduced when more sophisticated augmentative and alternative communicative assistive devices are used. This technology is continuing to be developed and a brain computer interface may be available that allows individuals without movement to communicate by using electroencephalography activity to control a cursor on a computer screen.109 Augmentative communication is an area where occupational therapists and speech-language pathologists work closely together. The most important message for treatment of individuals with locked-in syndrome is that they may be intact cognitively and linguistically. Therefore, it is important that staff use natural adult speech and language because patients react to style and tone of communication.35 In addition, to ensure that the patient is included in all decisions about care, staff should address the patient and the caregivers about the particulars of the rehabilitation plans.42
Some patients who are initially without speech progress to the point where they have some vocalization and some mobility of the upper or lower extremities.65 Small movements can be used to activate a switch for alternative communication. The emerging voice production is effortful, strained, and similar to the voice heard in individuals with spastic dysarthria.28,33 Even when the vocalization is limited to one sound, the individual can use the sound to call out to the caregiver. More articulate speech may not be possible, but some develop a small repertoire of words that are intelligible to familiar listeners. Communication can be enhanced by using the same strategies as identified for spastic dysarthria. The key points to remember are (1) give the patient lots of time to respond, (2) collaborate with the speech-language pathologist in designing low-tech tools that are visually and spatially accessible to the patient who has limitations in upper extremity functions, (3) indicate that you have understood the message by repeating it, and (4) validate the patient’s cognitive competence by treating the individual in an appropriately mature manner.92
Ataxic dysarthria (cerebellar lesions)
Most cases of ataxic dysarthria are not the result of stroke. Nevertheless, vascular lesions primarily in the posterior inferior cerebellar artery and anterior inferior cerebellar artery may result in ataxic dysarthria.28,33 Furthermore, ataxic dysarthria in stroke is rare. The primary speech symptoms are slow rate, abnormal prosody, and intermittently imprecise articulation.14,28,33 Typically the patient’s cognition is intact, but speech, though intelligible, may sound quite bizarre and unnatural.14,28,33,38
Rehabilitation of these communicative disorders is dependent on the patient’s age and vocational and avocational needs. The person may be more concerned with physical dysfunction than the speech changes, as the limb ataxia affects the ability to write, type, or use a computer mouse. These graphomotor disorders may affect more of the individual’s ability to communicate and require more intervention than the motor speech disorders. See Chapter 10. Team treatment with this type of dysarthria should recognize that these individuals probably have intact cognitive and language skills.
Mixed (any combination of the previous conditions)
Multiple strokes can affect various components of the motor speech system and result in mixed dysarthria. Certain combinations of dysarthria are more likely to occur than others are.28,33 The most common mixed motor speech disorder is a combination of an upper motor neuron dysarthria affecting the right side of the oral musculature and apraxia of speech.33 This combination occurs frequently in left middle cerebral artery strokes, and its symptoms are addressed in the discussion of aphasia. Moreover, single brainstem strokes might produce a mixed flaccid, spastic, and cerebellar dysarthria. This combination occurs because of the closeness of the upper and lower motor neuron brain structures and the proximity to cerebellar control circuits.33
Language disorders associated with stroke
Occupational therapists often question the speech-language pathologist about the complex and fascinating syndromes of acquired language disorders known as aphasia. Patients with aphasia say unusual and, at times, bizarre things. For example, a patient may make up a meaningless word (neologism) and use it as if it is a real word or take a real word and use it inappropriately (paraphasia).43 Symptoms such as a verbal stereotypy (saying a recurrent utterance such as “keep the key” or “ho doe ho doe ho doe” with appropriate melody and intonation) are remarkable phenomena.35,43 A patient with aphasia reports that he “knows exactly what I want to say, but the words don’t come out.” The person with aphasia searches for the number word to indicate the number of children he has and is forced to start with “one...two” and say the whole series until he arrives at the number word that he is trying to say.35,43
The unevenness of communication issues among the various language modalities is confusing to the professional unfamiliar with aphasia.35,43 For example, a patient may write normally but be unable to read what he or she has written, or a patient may not understand a word or sentence when spoken, but immediately “gets it” when it is written down.35,43 These unexpected combinations of language strengths and weaknesses pose challenges to the rehabilitation professional. Another issue surrounds the term “expressive” aphasia, which leads one to believe that there is no “receptive” component when in fact for most patients, the difficulty understanding language is the most functionally limiting component of the syndrome.43 Reduced auditory comprehension keeps persons with aphasia from returning to their work environment, participating comfortably in some social events, and enjoying language-based activities such as television, movies, and reading.55 The communication partner is prone to overestimate the patient’s comprehension of spoken language because the patient often appears to understand.37 This misconception is a reflection of the aphasic person’s socially appropriate affect and response to the environment and can lead to misunderstandings and miscommunication.37
Historically, aphasiologists have categorized aphasias differently depending on their particular bias.35,43 In the last half of the twentieth century, the most common categorization system was based on a classical typology which used the fluency of speech production and spoken language comprehension attributes to group the types of language issues.43 These classical groups are Broca’s, Transcortical Motor, Wernicke’s, Conduction, Transcortical Sensory, and Anomic aphasias. The most severe form is global aphasia and results from large or multiple lesions of the left hemisphere. Most modern aphasiologists simplify this classification into two general forms: nonfluent and fluent aphasia.43 It is understood that pure forms of any of these types are relatively rare (Table 20-1).
Table 20-1 General Suggestions for Improving Post stroke Communication
| GUIDELINES FOR ENHANCEMENT OF COMMUNICATION | |
|---|---|
| To enhance expression |
|
| To enhance comprehension |
|
Adapted from Hedge,51 and Simmons-Mackie,103
Broca’s aphasia
Broca’s aphasia, which many refer to as “expressive” aphasia, is regularly associated with a middle cerebral artery stroke affecting the third frontal convolution of the frontal lobe (classical Broca’s area, Brodmann’s areas 44 and 47)1,25,26,40 and extending into the white matter, the internal capsule. This lesion is anterior to the inferior portion of the precentral gyrus, clarifying the connection of this syndrome with the reductions in motor control in the right upper extremity.43,61,62,80,105 In the acute stage, these patients may be mute.43 Their speech production may evolve over the next few weeks to a few automatic expressions and perhaps a spoken “Yes.”43 These patients are typically alert, aware of their surroundings, and frustrated by the absence of speech.13,61 Their preserved affect can mislead the untrained observer to overestimate the language competency of the patient.100 The five main features of the evolving pattern are awkward labored articulation, difficulty initiating speech, reduced utterance length, telegraphic speech, and reduction in melodic contours.13,43 The following is an example of a patient with Broca’s aphasia describing the “Cookie Theft Picture.”43 See Fig 20-1.
Figure 20-1 The Cookie Theft picture.
(From Goodglass H, Kaplan E, Barresi B: The assessment of aphasia and related disorders, ed 3, Philadelphia, 2001, Lea & Febiger.)
“Boy . . . Cuh . . . Cuh . . . Cookie . . . girl . . . mama . . . kay . . . water . . . sinking . . . ice . . . ay . . . ch . . . ch . . . no . . . water . . . sinking . . . ee . . . why?” Given the limited flow of speech, one would think that little is being communicated. However, the words are substantive and appropriate, so that giving the patient with Broca’s aphasia time and using context to anticipate content allows the individual to be successful in communicating substance.35,42,61,95 In addition, using visual stimuli, key words, or simple pictures to supplement context and accepting gestures and drawing makes it possible for the patient with severe Broca’s aphasia to communicate not only thoughts and feelings but also specific information.18,71,99,101
The comprehension of spoken language in Broca’s or nonfluent aphasia is better than the production of speech, but it is far from perfect, at least in the early stages of the condition.43,61 Comprehension tends to improve faster in these types of aphasia than in other forms.61,62 Probably the major error made in working with patients with Broca’s aphasia is to overestimate the patient’s adequacy of comprehending spoken language.51 Some of the signs of overestimation are “the patient fails to carry out the activities that I have told him, and he understands everything I say” or “the patient comes at the wrong time . . . too early or too late . . .” Many patients with Broca’s aphasia do not process spoken number words. Providing a written appointment slip helps ensure that the patient with aphasia understands the scheduled appointment time. Communication can be further enhanced by using simple, clear direct adult sentences.51 Breakdowns of comprehension occur with complex grammar (tense, number, negation, comparison, words relating to space) that may be difficult for the patient.30 One needs to provide processing time for comprehension of more complex language,51,61,101 which can be done by inserting pauses between phrases or thought groups. It is a good idea to verify that the patient with Broca’s aphasia comprehends communication to him, no matter how intact the social behavior appears.
Reading and writing are also impaired in patients with Broca’s aphasia.61 Patients with severe Broca’s aphasia read the content words (nouns and verbs) and guess at the overall meaning of the sentences.43 Their ability to read improves over time, but the elements of asyntactic comprehension limit reading of most adult level reading material. Writing is impaired not only by the motor component, since the patient may have limited use of the dominant right hand, but also because of the language component.61 Spelling and letter formation may be extremely difficult. The use of computer-assisted programs may be helpful but are sometimes difficult. Some patients improve sufficiently to use computer-based typing, text messaging and e-mailing to communicate with friends.60
Recovery with Broca’s aphasia has a longer course than with other types of aphasia.6 In the authors’ clinical experience, persons with Broca’s aphasia can continue to improve their communication skills long after the acute stages. This improvement corresponds with an amelioration of the motor component associated with Broca’s aphasia (i.e., apraxia of speech) and a gradual improvement in speech comprehension.93 If in the early stages, the aphasia is mild, and it may improve to a relatively mild anomic aphasia or resolve almost completely.62,95
In the authors’ experience, occupational therapists often address functional language-based daily tasks. For example, following written instructions on medication, reading written instructions for upper extremity exercises, or following written recipes in the kitchen all have elements that can be most impaired in nonfluent aphasia. Any activity involving numbers (e.g., check writing and reconciliation of a bank account) may be impossible for the person with Broca’s aphasia to complete. It is important to set realistic therapy goals with respect to these tasks. Whenever possible, collaboration with the speech-language pathologist may be helpful when planning compensatory and supportive techniques to facilitate these language-based activities.
Apraxia of speech
Apraxia, a common speech disorder resulting from a middle cerebral artery stroke, is controversial,2 because aphasiologists have described it differently according to different theoretical biases. Duffy33 listed 25 different terms for apraxia of speech that researchers have used to define it. Many speech-language pathologists, including Duffy, view it as a separate specific type of motor speech disorder independent of aphasia.33 However, in the authors’ experience, this motor disorder that is not dysarthria usually occurs with a nonfluent Broca’s aphasia or mixed dysarthria. Speech production is effortful, slow, and dysrhythmic, resulting in impaired prosodic variation (i.e., melody of speech).28,33,38 The cardinal feature articulatory effort is visible and is apparent groping for the articulatory positioning and sequencing.33,38 These patients are generally aware and frustrated by their speech disorder and say things such as “I know what I want to say but it will not come out.”13,28,33 In addition, these individuals have great difficulty imitating words and phrases.28,33,38
In general, these individuals are highly motivated to improve their speech and are unusually focused on their speech production.28,33,38 In the authors’ experience, their concentration on the speech component can be so strong that it supersedes their interest in other therapies and overrides efforts to ameliorate other linguistic disturbances. Although it would seem reasonable to introduce supplementary or communicative alternatives (i.e., a communication book or a computerized communication device), the authors find that these patients initially reject these devices. Interestingly, younger patients who are familiar with text messages and e-mail are more receptive to facilitating their communication through these avenues.
It is helpful for the occupational therapist to remember that these patients may have a subtle language comprehension disorder despite their appearing to be completely cognitively intact.28,33,38 Their struggle may be alleviated by providing additional time to communicate, giving verbal choices, using supplementary written material, and having an attitude of calmness around their communication.33,38 Typically, the listener is counseled not to provide a word when it is known what the individual is attempting to say, but in this case, for efficiency, the occupational therapist might choose to do so with the patient’s permission.
Prognosis for individuals with apraxia of speech ranges depending on the severity of the apraxia and the underlying linguistic disorders.38 However, patients with good comprehension tend to improve over a longer period and clear to a milder version of apraxia of speech.38,107 Slow speech, intermittent articulation errors, and reduced prosodic variation may persist in the chronic state.38,107 Nevertheless, their communication is effective. The authors find that these individuals can become the advocates for public awareness of aphasia, because they are intensely focused on the alteration of their speech and its impact on their lives. See Table 20-2.
Table 20-2 Suggestions for Improving Communication: Broca’s Aphasia and Apraxia
| BROCA’S APHASIA: SPEECH AND LANGUAGE SYMPTOMS* | GUIDELINES FOR COMMUNICATION ENHANCEMENT† |
|---|---|
| May be mute at onset Impaired “flow” of speech Halting and hesitant speech Impaired prosody and intonation Awkward effortful articulation Short simple utterances Telegraphic style Intact content with poor sentence structure and grammar Self-correction of errors Aware of errors and frustrated Impaired speech repetition Impaired comprehension Dyslexia (reading problems) Dysgraphia (writing problems) Dyscalculia (calculation problems) |
Give patient plenty of time to speak Encourage participation in conversation Encourage patient to use alternate means of communication (gesture, drawing) Use visual supports (key words, word books) Ask the person to tell you if he or she wants you to fill in the missing words If you do not understand what the person is saying, let him or her know Pay close attention to body language and facial expression Try not to over estimate comprehension Write down numbers (time, date, address, etc.) Avoid using semantically reversible sentences like “the girl was hit by the boy” Simplify grammatical structures when you do ADL tasks, (e.g., before/after, negatives, comparatives) Ask SLP regarding level of reading comprehension before giving written instructions Highlight key words Pair written words with auditory stimuli (electronic books) Enlarge print as necessary Provide model for written material |
| APRAXIA OF SPEECH: SPEECH AND LANGUAGE SYMPTOMS‡ | GUIDELINES FOR COMMUNICATION ENHANCEMENT ‡ |
| May be mute at onset Speech symptoms are often similar to the previous symptoms listed with the addition of: |
Strategies for enhanced expression are the same as the ones previously listed For the patient with severe apraxia of speech augmentative and alternative devices may be considered May not require the modifications for comprehension indicated previously |
SLP, Speech-language therapist.
* Adapted from Goodglass and associates43 and Hedge.51
† Adapted from Hedge51 and Simmons-Mackie.103
‡ Adapted from Duffy.33
Transcortical motor aphasia
Transcortical motor aphasia is a rare type of aphasia is due to a small subcortical lesion superior to Broca’s area, or to a lesion outside of the anterior language areas of the left hemisphere.26,40 Because of the location of the lesion in the frontal lobe, transcortical motor aphasia includes both language and cognitive components. The person with transcortical motor aphasia has difficulty spontaneously initiating speech but repeats even long sentences effortlessly and accurately.43,62 Consequently, the listener is required to initiate the topic and to structure the question in order to facilitate a verbal response.2,69,92 For example, when asked an open-ended question such as “what did you do yesterday?” the patient is known to say, “ I . . . I . . . I can’t . . . I can’t . . . yesterday . . . I did many things.” However, when asked to describe a picture, the output is in the form of a simple declarative sentence that is usually grammatically correct, appropriate, but lacking in elaboration.
The main communication problem in transcortical motor aphasia is maintaining the flow of fluent speech, which is due to an underlying difficulty organizing the content of communication.89 This form of aphasia displays cognitive failures that result in limited and disorganized output both in speech and writing.92 However, comprehension of spoken language or even syntactically complex sentences are often well-preserved.43 Frequently, reading comprehension and oral reading are also excellent.59
The patient with transcortical motor aphasia may be indifferent to the reduction in his communication.13 In the authors’ experience, the patient’s apathy elicits frustration in the staff working with him or her because they may overestimate his or her ability to perform. The staff may expect the patient to initiate the use of a memory book, to structure a meaningful activity, or to set priorities for daily activities, none of which this patient can do without prompting. The authors have found that the patient requires structure and repetition to perform and constant prompting to initiate and follow through with tasks. The patient’s lack of appreciation of the goals of therapy and inability to connect the procedures to the goals impedes his ability to respond to treatment.2,42,69
If the transcortical motor aphasia is mild in the early stages, it may resolve to an anomic variety.43,92 Nevertheless, the authors have found that persistence in the reduction of speech initiation and organization of discourse may prevent the patient from resuming normal social and vocational activities. These deficits most likely reflect dysexecutive function that may be more debilitating than the language disorder.9
The occupational therapist can facilitate communication with the patient who has transcortical motor aphasia by structuring the communication environment and providing many cues for communication. Despite the preservation of some communication modalities, the individual is dependent on the listener to initiate, maintain, and repair conversation breakdowns.69 In addition, the patient will need prompting to use his or her calendar, notebook, and other augmentative systems. See Table 20-3.
Table 20-3 Suggestions for Improving Communication: Transcortical Motor Aphasia
| TRANSCORTICAL MOTOR APHASIA: SPEECH AND LANGUAGE SYMPTOMS* | GUIDELINES FOR COMMUNICATION ENHANCEMENT† |
|---|---|
| May be mute at onset Difficulty initiating speech Flat affect Sentence repetition is fluent and effortless Sentence length is reduced Comprehension of spoken and written language is generally spared Impaired executive function (i.e., organization of speech output, narrative skills, all varieties of discourse, engagement evident both in spoken and written output) |
Prompting required for speech engagement and initiation: Prompt the patient to use a notebook for daily activities Use written cues to prompt communication (i.e., when asking patients if they did their exercises, write down the anticipated response) |
Fluent aphasias (wernicke’s, conduction, transcortical sensory, and anomic)
Fluent syndromes are relatively common among elderly poststroke patients. These individuals may not be referred for occupational therapy if they do not present with concurrent difficulties in daily living. However, some of these patients have a right visual field cut, and they may eventually find their way to occupational therapy for evaluation and treatment. The major language characteristics of fluent aphasia are the ease of speech production and the normal utterance length.43 Various types and severities of speech characteristics are found among the fluent syndromes. In addition, a variety of speech comprehension, reading, and writing deficits may occur.43
Wernicke’s aphasia
The diagnosis of Wernicke’s aphasia rests on a triad of characteristics, including fluent paraphasic speech, reduced speech comprehension, and anosognosia (lack of awareness of the erroneousness of output).43 Although speech is produced with normal fluency and prosody, the content is severely limited.43 Speech contains a mixture of real words and neologisms (made up new words) and usually is empty of meaning.13,45 The severe reduction in nouns and verbs and vagueness of content is reflected in the following example. When shown the Cookie Theft picture43 (Fig. 20-1), a patient said “had that before . . . chories . . . this guy is a messo . . . she is okay. He has a mess on . . . all over here. She is just stupid. Oh, what is that? That’s just . . . those are nice, pretty . . . and that’s a mess and then goots (cups). He’s pretty stupid. She is okay. She’s cute. This is inside . . . outside.” These patients have been incorrectly labeled confused or demented, or diagnosed with having psychiatric disorders when in fact the syndrome of aphasia causes the bizarre output.74
In the early stages, a patient with Wernicke’s aphasia may be unaware of his or her language disorder, deny that he or she has had a stroke, and confabulate the reason for the hospitalization.13,43,45 Since a patient is unable to understand what is being asked of him or her and is unaware of his or her deficits, initial language testing may make little or no sense to him or her.13,29,45 The patient’s willingness to participate in therapy increases as spontaneous recovery of language occurs and he or her develops more insight into the nature of his or her communication problem.29,45 He or she begins to have a nagging awareness of something amiss in the process of communication, but he or she may not recognize that the communicative breakdown is due to aphasia.
People with Wernicke’s aphasia are said to have “receptive aphasia.” This term suggests that their communication difficulty is simply a failure to understand spoken language.45 However, from the previous description, aphasia obviously has both receptive and expressive components. Furthermore, comprehension of spoken language is uneven and at times unexpected.43,45,99 For example, the authors have found the simple instruction “pick up the spoon and put it in the bowl” is usually more difficult than the whole body command “stand up and turn around.” If the person catches the right word or interprets the context sufficiently, responses may be surprisingly appropriate and may obscure the severity of the language comprehension problem.43,45,74
Comprehension can be facilitated by discussing topics of personal relevance, giving the patient time to process the information, signaling changes in topic, stating the same idea in different words, and providing visual cues.74 The staff also needs to remember the patient’s difficulty in detecting a communication breakdown, so it is up to the communicative partner to fill in and assist in any way possible with the needed repair.45 Comprehension of written language is impaired so that use of written cues, written homework, and schedules may not be helpful for these patients, particularly in the early stages.74 Most of these patients will have no right upper extremity weakness and that writing may be fluently executed. However, the content of writing samples usually mirrors speech production and contains neologisms, meaningless content, and inappropriately spelled words.43,74
Depending on their social behavior and their communication partners, these individuals can live a rich life after stroke.74 In time, many patients with Wernicke’s aphasia successfully use a “communication book” that contains nouns of personal relevance.106 Some of these patients are remarkably independent despite the global severity of their aphasia.74 See Table 20-4.
Table 20-4 Suggestions for Improving Communication: Wernicke’s Aphasia
| WERNICKE’S APHASIA: SPEECH AND LANGUAGE SYMPTOMS* | GUIDELINES FOR COMMUNICATION ENHANCEMENT† |
|---|---|
| Speech initiation is easy (hyperfluent) Fluent uninterrupted strings of words Well-articulated Neologisms and verbal paraphasia Jargon Grammatically coherent: small words fall into place automatically Inability to repeat words Intact prosody and intonation Little awareness of errors Poor speech comprehension Unaware of comprehension limitation Dyslexia and dysgraphia |
Stop strategy: Use gestures to cue a patient to stop the flow of speech Refocus patient to change topics Provide written nouns (key words or pictures to convey information) Allow circumlocution Simplify written and spoken material Provide meaningful contexts for tasks—personal relevance is helpful Speak slowly clearly and at normal loudness levels Face the person when you talk to them Give the person time to understand Write down key words to change topics and support comprehension Use common words and simple direct sentence structures Say the same thing differently Rely on the speech-language pathology evaluation to guide choice of reading material level Anticipate writing difficulty |
* Adapted from Goodglass and associates43 and Hedge.51
† Adapted from Marshall.74
Conduction aphasia
The neuroanatomical correlate for conduction aphasia is somewhat controversial, but most agree that it is usually due to a small lesion in the supramarginal gyrus.26
The outstanding feature of conduction aphasia is relatively fluent spontaneous speech with disproportionately poor sentence repetition.13,43 Spontaneous speech is characterized by “abundant literal paraphasias”13 (sound substitutions), especially in the early stages. The progressive approximation or targeting of sound sequences is common. For example, to say the word “bench,” the individual may make the following attempts to arrive at the required word “chench . . . nech . . . pench . . . spench . . . bench.” These word finding problems and anomia can range from mild to severe.13,102,103 Persons with conduction aphasia also have difficulty reading aloud and make frequent sound errors.13 This function improves over time but limits the use of written scripts as a treatment procedure. Writing varies in effectiveness, but graphic production typically contains some errors in grammar, spelling, and word retrieval.13 Patients with conduction aphasia are aware of their errors and may be highly frustrated by their inability to properly string together the sequence of sounds required to say polysyllabic words such as “statistical analysis.”43 This syndrome is fairly rare and has a relatively good prognosis, evolving in time to a mild anomic aphasia.13,102,103
It is the authors’ experience that when working with this group, professionals need to support the patient’s attempts to communicate by being an active communication partner and accepting imprecise productions. The production of complex scientific terms, medical terminology, and the names of pharmaceuticals will always be difficult for the patient with conduction aphasia. Inaccurate production of words, if the words resemble the target sufficiently, may not limit the transfer of ideas. The therapist should avoid requesting verbatim repetition of instructions including repetition of numbers (telephone numbers, dates, etc.) and recall of specific complicated words. Communication can also be improved by realizing that the person probably understands even complex language, reads sophisticated material silently, and responds well to cues. In addition, the person can learn new material and develop new skills.102,103 See Table 20-5.
Table 20-5 Suggestions for Improving Communication: Conduction Aphasia
| CONDUCTION APHASIA: SPEECH AND LANGUAGE SYMPTOMS* | GUIDELINES FOR COMMUNICATION ENHANCEMENT |
|---|---|
| Fluent conversational speech, but unusually poor speech repetition Abundant literal paraphasia (sound substitutions) Some word substitutions Polysyllabic words are more difficult than shorter words Naming is variable (from poor to good) Preserved speech comprehension Oral reading is poor; characterized by words containing phonemic paraphasia (literal) Silent reading comprehension is good Writing can be comparable to speech |
Refrain from expecting verbatim repetition of numbers, words, sentences Allow circumlocution Encourage alternate methods of supplying target words Give plenty of time to express self Encourage patient to use shorter simpler words or to use pantomime Encourage patient to use own cueing strategies Refrain from activities requiring reading aloud, e.g., scripts Rely on the speech-language pathology evaluation to guide writing activities |
Anomic aphasia
Since all syndromes of fluent aphasia are characterized by a reduction in the retrieval of nouns, the use of the term “anomic aphasia” becomes arbitrary, as it is both a symptom and diagnostic category.13,41 It is also well-accepted that anomic aphasia is regularly the end point of other aphasias, and because of this feature, there is no one neuroanatomical site associated with the classification of anomic aphasia.13
According to Goodglass, Kaplan, and Barresi,43 the “major feature of anomic aphasia is the prominence of word-finding difficulty in the context of fluent, grammatically well-formed speech.”43 There are few paraphasias, and comprehension is “relatively intact.”43 Patients with anomic aphasia may be underidentified because their speech is fluent and their content is substantive. In contrast, on confrontation naming tasks, their speech is “empty” and they use frequent circumlocutions. Their naming difficulty poses a significant functional limitation in situations where clear, concise verbal function is required.13
In anomic aphasia, comprehension of spoken and written material is marred by subtle deficits.13 For example, the patient may have no difficulty following conversation when talking about pictures in a photograph album or listening to a paragraph about current events where context supports comprehension.43 On the other hand, the authors have found that they may do rather poorly on specific nonredundant content (e.g., the Revised Token Test instructions, “Point to the green square and the white circle.”)78
The occupational therapist needs to be aware that it is easy to miss the language deficits in individuals with anomic aphasia and needs to look for difficulty with confrontation naming. For example, these patients have difficulty both saying and understanding unfamiliar names (staff members, pharmaceuticals, locations, and names of medical conditions), putting them at risk for making errors.42 The listener might be tempted to overestimate the communicative skills of the person with anomic aphasia and to expect the individual to return to work. Therefore, recognizing the disorder and developing strategies that enhance the person’s ability to perform on the job are essential.42 The authors find that collaboration with the vocational rehabilitation counselor facilitates reintegration into the individual’s work life (Table 20-6).
Table 20-6 Suggestions for Improving Communication: Anomic Aphasia
| ANOMIC APHASIA: SPEECH AND LANGUAGE SYMPTOMS* | GUIDELINES FOR COMMUNICATION ENHANCEMENT |
|---|---|
| Object naming is disproportionally impaired relative to preserved speech fluency Word substitutions and circumlocution are common Repetition is sometimes quite preserved Comprehension of spoken and written material relatively preserved but variable Writing parallels speaking |
Allow patient to refer to word lists to locate target word Encourage patient to describe target noun Allow circumlocution Refrain from confrontation naming tasks Ask patient if he or she wants the listener to supply the word Consider use of word prediction software for writing tasks Refrain from overestimating adequacy of comprehension |
Global aphasia
Global aphasia is common, especially in the acute phase after a large left middle cerebral artery stroke.26,40 Sometimes this aphasia is also found when a patient has two or more smaller left hemisphere strokes.26 The main feature is that all language modalities are severely impaired.18 It is important to remember that “global” when describing aphasia does not mean “total.”18,19 Speech may be limited to automaticisms (“yes,” social greetings, and curse words) and recurrent utterances (e.g., “ah-dig-ah-dig-ah-dig” or “television . . . television . . . television”). Speech repetition can be limited to serial speech (counting, days of the week, and overlearned material such as prayers and lyrics of familiar songs).43 In the early stages, patients with global aphasia have only rudimentary comprehension of spoken language. The patient appears to rely almost entirely on facial expression, vocal intonation, and contextual cues to understand others. Speech comprehension almost always improves to some extent; some patients can be reclassified as a milder aphasia, such as Broca’s or conduction aphasia.18 However, speech comprehension remains impaired in many cases, and small gains in language comprehension do not always change the aphasia diagnosis.18 In the beginning, reading may be restricted to familiar nouns and verbs, and writing is usually limited to random lines on a page or single letters. Writing of one’s own name and some numbers may improve in time. In the chronic phase, gestures and nonoral means of communication are often effective compensations for the severe reduction in language abilities.18
Patients with global aphasia may be withdrawn and unaware or they may be alert, oriented, and extremely aware.18 The alert patient is usually described as having better comprehension than is actually the case.101 Frustration tolerance is variable and may be related to the patient’s self-awareness.18
To facilitate rehabilitation, the occupational therapist should speak to the patient in direct, short instructions that pair simple and explicit language structures with modeling and manual cues18 (i.e., “right arm first” followed by a gentle touch on the right arm, rather than “don’t use your left arm for this”) The mere use of too many words may overwhelm the individual with global aphasia.18 Communication partners need to be aware that gestures and facial expressions are cues that the patient with global aphasia uses to understand his or her world.18 Therefore, clinicians need to pay attention to facial expression and use a natural and appropriate vocal tone.18 The simple social language used to begin conversations is necessary in establishing rapport and trust.18 Topic shifting is enhanced if the communicative partner uses visual prompting such as providing key word choices from which a patient can choose the word(s). The writing of key words to support communication is essential in enabling the patient to participate actively in conversation.18,58 In a therapeutic session, it is helpful to limit the goals and procedures to one or two, provide breaks, extra time, and a set routine to facilitate successful communication in individuals who have global aphasia.18 See Table 20-7.
Table 20-7 Suggestions for Improving Communication: Global Aphasia
| GLOBAL APHASIA: SPEECH AND LANGUAGE CHARACTERISTICS* | GUIDELINES FOR COMMUNICATION ENHANCEMENT† |
|---|---|
| All aspects of language are severely impaired Speech limited to automaticisms (e.g., “yes” “OK” numbers in series) Unable to repeat Unable to produce speech sounds voluntarily Jargon may be present Auditory comprehension limited to simple material of high personal relevance Appears to understand when patient does not Silent reading limited to recognition of own name Unable to read aloud Unable to write words Awareness of/reliance on social cues may be good |
For both expression and comprehension:
Rely on visual (nonlanguage) cues Facial expression, body language Emphasize important words in a sentence Provide simple verbal or written word choices when appropriate Keep all stimuli personally relevant Accept any and all modes of communication Encourage inclusion in social conversation and singing activities Encourage speech activities (e.g., counting, prayers) Focus on doing things together rather than talking about things |
* Adapted from Goodglass and associates43 and Hedge.51
† Adapted from Simmons-Mackie.103
Cognitive communication impairment
Common etiologies of cognitive communicative impairment are right hemisphere stroke and vascular dementia (formerly known as “multi-infarct dementia”).84 The unifying factors for this disorder are reductions in attention, concentration, memory, and problem-solving. The impact of these factors ranges widely, and the resulting communication disorder is complex.84
Right brain
Although most patients with a right brain stroke “do well in straightforward conversation,”84 their communication abilities are not “normal.” Some individuals with right brain damage have speech and/or language problems and an upper motor neuron dysarthria.84 This dysarthria is characterized by slight imprecision of articulation, harsh voice quality, and monotonal delivery.33 Rarely is overall speech intelligibility affected.33 These patients often lack appropriate and meaningful vocal inflection, and emotional display is blunted.84 In addition, speech rate, rhythm, and melody are sometimes abnormal.33 Some right brain damaged (RBD) patients also have mild language deficits and display difficulty on clinical tasks such as confrontational naming, divergent naming (category naming), and word recall.84 These language problems seem more related to cognitive deficits of attention and memory than language dysfunction.84 Frequently, there is a reduction in comprehension of word meanings and difficulty processing metaphors that result in unusual and concrete decoding of language.83 On rare instances, RBD patients present aphasia; however, the aphasia is atypical (also known as “crossed aphasia”).26,83
Another component of right brain injury cognitive communicative impairment is an alteration in pragmatic communication and discourse.84 When describing an event, the patient with right brain communicative deficits will become tangential and overly detailed and show a tendency toward hyperverbosity.87,88 Although relatively infrequent, some patients use confabulation to make up stories to help them explain events that they do not understand.83 The patient’s discourse is sometimes redundant and irrelevant.84 These issues can be seen in this description of the “Cookie Theft” picture43 (see Fig. 20-1): “The woman just got home from work and she is thinking about dinner. She might go to the restaurant so doesn’t have to cook and clean up. The kitchen is pretty clean for someone who works. The curtains are clean.” This description highlights the communication issues frequently observed in RBD patients: the absence of the relationship of the individuals in the picture (woman rather than mother), irrelevant and tangential content that misses the activity of the picture (washing the dishes and ignoring her children), misses the emotion (the woman’s distraction while the water overflows the sink), neglect of the left side of the page (the description misses the children on the left side of the picture), and the focus on inconsequential details (“the curtains are clean”).
Furthermore, a lack of insight and concreteness may reduce the patient’s ability to participate in the setting of rehabilitation goals. Goals, such as reducing impulsivity or increasing safety awareness, have little meaning to the RBD patient. For example, when the authors ask the patients if they have noticed that they tend to neglect the left side of space, they probably will deny the problem.84 However, they may readily acknowledge that people repeatedly tell them “look to the left.” In the authors’ experience, the patient will not appreciate the goal or meaningfulness of the activity unless the therapist makes the consequence of the neglect evident to the patient (i.e., not seeing dangers on the left). In the authors’ experience, clinicians sometimes ascribe the failure to work productively in treatment to a lack of motivation or decreased initiation. However, the failure seems, to the authors, most likely a consequence of the alterations in cognition, particularly the reduction of insight.84 This failure to derive implied meaning from what is said affects decisions at every stage of the rehabilitation process.84 The patient may not understand that his or her impairments affect the ability to live independently or return to work because of his or her inability to connect the impairment with the failure to negotiate the tasks of daily life.
The cognitive communication deficits described previously are exacerbated by nonlinguistic communicative impairments that include left neglect, reduced and disturbed attention, anosognosia (failure to recognize deficits) prosopagnosia; and visual and spatial perception deficits.73,83 The factors that most affect communication are neglect, inattention, reduced awareness, and impulsivity. The failure to respond to speakers in the left visual field affects the pragmatic interaction with communication partners.5,73,84 In addition, left neglect can be paired with cognitive issues that affect reading and writing.73,84 Difficulty reading prescriptions and inadequacies in filling out medical forms affect the patient’s compliance in medical care. While these skills are not central to communication, they seriously influence the rehabilitation team’s decisions about prognosis, discharge, and burden of care.84
Little is known about the recovery of communication deficits in the RBD patient.73,84 Speech-language pathology intervention is frequently focused on specific tasks that show concrete changes.84 Direct unambiguous cues can sometimes be successful in inhibiting the hyperverbosity.84 When working on a task that requires listening to directions, following written instructions, writing checks, or filling out forms, the attention and concentration impairments are being addressed in concrete everyday communicative tasks. There is literature on improvement of left neglect5 in reading and writing, an area of possible collaboration between speech-language pathology and occupational therapy. See Chapter 19.
Vascular dementia
This underappreciated dementia32,81 was formerly known as “multi-infarct dementia” or “hardening of the arteries,” and it may resemble Alzheimer disease in the severity of the functional cognitive impairments. But vascular dementia differs from Alzheimer in important characteristics.54 While the disease is progressive, it is stepwise rather than sloping in progression.46 There are periods of slight but sometimes meaningful improvements in communication.90 In general, the disease is most often described as “microvascular” or “small vessel disease.”81 The symptoms are heterogeneous and based on the lesion site.54
Prognosis is dependent upon effectiveness of medical treatment for hypertension and on anticoagulation.90 Early on, the progression may be slow and subtle with little specific functional difficulty, so that many of these individuals are never hospitalized or evaluated by rehabilitation professionals.54 Patients are usually identified after a major stroke or other medical event.90 Their rehabilitation course must take into account the severity of cognitive impairment.54 Strategies used with other forms of dementia (e.g., low-tech memory and communication systems such as memory notebooks or wallets) are sometimes helpful in assisting patients become better oriented and foster improved communication.54 Occupational therapists and speech-language pathologists regularly work together to establish the goals and determine content and use of these augmentative systems. Many of the techniques and suggestions made for people with aphasia or right hemisphere damage are appropriate (i.e., giving time to process information, speaking in direct simple sentences). Prognosis for this common progressive vascular disease is unstable and variable.54
Summary
In acknowledging the complexity and centrality of human communication, this chapter has emphasized the importance of the changes in communication that often follow stroke.
The stroke-related communication difficulties encompass a broad range of disorders, each with its own unique characteristics. Having an understanding of the relative strengths and difficulties of the various communicative disorders allows the occupational therapist to detect and understand the communicative issues their stroke patients present. Better understanding of speech, language, and cognitive disorders can only increase communicative competence and minimize the impact of the patient’s communication disorder on rehabilitation.
Review questions
1. What is the difference between Broca’s aphasia and apraxia of speech?
2. Name three strategies that would be helpful when working with a client presenting with Wernicke’s aphasia.
3. Name three strategies that would be helpful when working with a client presenting with Broca’s aphasia.
4. Name three strategies that would be helpful when working with a client presenting with global aphasia.
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