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

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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

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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

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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.

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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)

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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

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Stroke Right Hemisphere

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

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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

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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

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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

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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

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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

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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

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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

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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

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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)