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Facilitating Communication in Individuals with Neurological Disease

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Johns Hopkins University School of Medicine. Stroke: Aphasia, Apraxia of Speech &/or Dysarthria ... The Visual Dictionary. Communication Notebook. Ex: Chapter ... – PowerPoint PPT presentation

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Title: Facilitating Communication in Individuals with Neurological Disease


1
Facilitating Communication in Individuals with
Neurological Disease
  • Argye E. Hillis, MD, MA
  • Johns Hopkins University School of Medicine

2
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

3
Nonfluent (Brocas) 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

4
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.

5
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

6
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

7
Stroke Fluent (Wernickes) 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

8
Stroke Wernickes Aphasia
  • Facilitate expression
  • If you dont 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

9
Stroke Wernickes 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

10
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-gt cork or hork
  • Fort-gt spoon

11
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

12
Communication NotebookEx 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

13
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

14
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

15
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)

16
Dysarthria Facilitate expression
  • Ask them to rephrase, not just repeat, if you
    dont 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

17
Stroke Right Hemisphere
  • Trouble with abstract language
  • Metaphors
  • Analogies
  • Proverbs
  • Jokes
  • Trouble understanding vocal intonation, facial
    expression, gestures
  • Limited intonation, facial expression, gestures

18
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 dont
    rely on facial expressions gestures
  • Facilitate expression
  • Ask him or her to tell you his/her emotions

19
ALS Lou Gherigs 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

20
ALS Facilitate expression
  • Ask them to rephrase, not just repeat, if you
    dont 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

21
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

22
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

23
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

24
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

25
Dementia
  • Alzheimers 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

26
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

27
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)
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