please understand me tips for health care professionals assisting clients with aphasia

1. Linda Wetterau, RN, BSN April, 2007

2. The Aggravation of Aphasia Aphasia is a partial or total loss of ability to talk; and/or understand what people say, read or write. Aphasia is a symptom and not a disease, and can occur in a variety of brain injuries. As a healthcare provider, you have a unique opportunity to assist those affected with aphasia to achieve improved communication. Used with permission from L. Johnston, “For Better or For Worse” syndicated comics

3. Objectives This tutorial is designed to help you: Exhibit recognition of brain anatomy Name the functions of the brain Describe neuron pathways and communication mechanisms Describe major types of aphasia Relate physiology of aphasia to client signs and symptoms Describe appropriate nursing interventions as related to nursing sensitive outcomes

4. Learning to Help Choose a topic of interest from the menu or simply click on the forward arrow to progress through the program. Selecting the back arrow will take you to the previous slide. To return to this menu click on Brain Anatomy

5. Brain: The World Inside Your Head

6. Brain: The World Inside Your Head

7. Brain: The World Inside Your Head

8. Brain: The World Inside Your Head

9. Time for Review---Name your Brain

10. Name your BrainClick on the region which corresponds to the following description:

11. Name your BrainClick on the region which corresponds to the following description:

12. Name your BrainClick on the region which corresponds to the following description:

13. Name your BrainClick on the region which corresponds to the following description:

32. Sorry—this is your “motor center”—the cerebellum. The occipital lobe is the smallest of the regions in the cerebrum and is located in the posterior portion of the brain. Please click here to try again!

39. Brain Communication

40. Brain Communication

41. Brain Communication

42. Brain Communication

43. Communication Breakdown The workings of these neuron pathways convey perceptions and states of mind we can recognize and put a name to---making it possible to exchange signals as language. Words are encoded by formation of networks of neurons. In aphasia, this chain of signals has been interrupted. Aphasia can occur as a result of: Brain injury Stroke Cerebral tumors Degenerative diseases

44. Pathophysiology of Aphasia This injury causes an interruption of the brain’s blood supply. Diminished perfusion leads to inadequate oxygenation to the affected area. The tissue’s metabolic activities are impaired with resulting loss of neuronal functions and interruption of electrical pathways. This chain of reaction is known as the “ ischemic cascade”.

45. Pathophysiology of Aphasia Key processes include an influx of calcium with resultant glutamate release, acidosis and free radical production. In later stages, secondary inflammation and local cell destruction (apoptosis) occur. As a result, the intricate functions of language are interrupted.

46. Aphasia Syndromes Patients with aphasia have usually sustained an injury to the left cerebral hemisphere. The left hemisphere tends to be the more analytical part, taking information and applying language to it.

47. Aphasia Syndromes For example, the right hemisphere “sees” a car and this information is transmitted to the left hemisphere which says “There is Joan’s new convertible”. The specific language deficit will vary according to area of brain injury.

48. Aphasia Syndromes Cognitive and linguistic deficiencies are grouped into aphasia syndromes. These classifications are expanding as neuroscience research develops. Click on each of the most currently accepted categories below for description: Broca’s Wernicke’s Conduction Global Transcortical

49. Broca’s Aphasia Syndrome Using the information you learned in the overview of brain anatomy, answer the following question: Broca’s area is the center for expressive language and is located deep in the frontal lobe.

50. Wernicke’s Aphasia Syndrome Using the information you learned in the overview of brain anatomy, answer the following question: Wernicke’s area is the center for receptive language and is located in the temporal lobe.

51. Conduction Aphasia Syndrome Also known as associative aphasia, this is a relatively rare form of aphasia, thought to be caused by a disruption in the fiber pathways connecting Wernicke’s and Broca’s areas. Affected individuals show the following characteristics: speech is fluent with good comprehension oral reading is poor major impairment in repetition transposing sounds within a word (i.e. using “velitision” instead of "television“) are common.

52. Conduction Aphasia Syndrome To understand the symptoms, recall that Broca’s area is associated with expression and Wernicke’s area with understanding. With both areas intact but the neural connections between them broken, the result is that the patient can understand what is being said but cannot repeat it (or repeats it incorrectly). This patient will also end up saying something inappropriate or wrong, realize his/her mistake, but continue making further mistakes while trying to correct it.

53. Global Aphasia Syndromes Global aphasia is the most severe form. The symptoms are those of Broca’s aphasia and Wernicke’s aphasia combined. There is an almost total reduction of all aspects of spoken and written language, in expression as well as comprehension. However, other cognitive skills remain functioning, so the client is aware of their deficit!

54. Transcortical Aphasia Syndrome Transcortical aphasia is a relatively rare condition which occurs when the area of injury surrounds, but does not affect Broca’s or Wernicke’s area. An affected individual will have both severe speaking and comprehension impairment. The ability to repeat is retained, making repetition the defining quality of this syndrome.

56. When damage occurs in Broca’s area, individuals will have difficulty with expression of language. Speech will be slow and labored, without intonation, but meaningful. Affected people often speak in short, incomplete sentences—omitting functor words such as “is”, “and”, “the”. For example, a person with Broca’s aphasia may say “water now” which may be interpreted as “I would like some water now” or “I need to water the plants now” or any of a variety of meanings. Naming of actions is typically harder than naming of objects. Some difficulty in reading is also common. As spontaneous speech is challenging, this syndrome is often called “nonfluent aphasia”. As cognitive comprehension is NOT impaired, affected individuals often suffer from depression, anger, and frustration at their disability. Click here to continue

57. Since Wernicke’s area is responsible for the ability to understand language, individuals with damage to this area exhibit impaired comprehension of speech—both their own and that of others. Therefore, affected people speak easily, giving this syndrome the description of “fluent aphasia”. However, the long sentences are filled with the wrong words, wrong sounds in words, or even made up words (known as neologisms). These individuals are unaware of their deficit, and therefore often appear “confused”.

58. SORRY—that is incorrect. Since Wernicke’s area is responsible for the ability to understand language, individuals with damage to this area exhibit impaired comprehension of speech—both their own and that of others. Therefore, affected people speak easily, giving this syndrome the description of “fluent aphasia”. However, the long sentences are filled with the wrong words, wrong sounds in words, or even made up words (known as neologisms). These individuals are unaware of their deficit, and therefore often appear “confused”.

59. Aphasia-- What is the prognosis?

60. Aphasia-- What is the prognosis? In general, patients tend to recover skills in language comprehension more completely than those skills involving expression. The goal of treatment is to restore as much independence as possible. This is done in a way that preserves an individual’s dignity while motivating them to re-learn basic skills

61. Remember the role of neuron networks in language? Research has shown that stimuli repetition “retrains” the brain, creating new wiring connections to replace lost ones “Rewiring” of communication pathways begins within weeks of injury and can continue for years. Aphasia--Recovery

62. Aphasia--Recovery As it receives repeated input, the brain physically changes its structure. New blood vessels begin to form and newly born neurons migrate to the damaged area. Therefore, provided the correct challenge and environment, an aphasia victim can achieve optimal communication.

63. Aphasia--Treatment The most effective treatment begins early in the recovery process and is maintained consistently and intensely. Therapy is aimed at improving a person's ability to communicate and includes: Medical and nursing supportive treatment Physical therapy Occupational therapy Speech therapy

64. Nursing Interventions Supportive actions during the client’s acute phase will include: Maintaining oxygen saturation to nourish the brain Ensuring adequate nutrition to “feed” neuron pathways Performing regular neurological assessments to monitor for client changes (i.e. Glasgow Coma Scale)

65. After survival, our most basic human need is to communicate with others. Aphasic individuals report feelings of isolation and alienation—leading to frustration and depression. Remember, the person’s intelligence is NOT affected by their disability.

66. Nursing Assessment Therefore, after assessing the client’s vital signs and neurological status, validation of their communication abilities will be a priority. Important functions to assess include:

67. An important nursing goal will be to provide a sense of security for our clients; ensuring that they know they are not alone and that others DO care. Ongoing nursing interventions are then targeted toward maximizing the client’s ability to communicate. Specific outcomes will be focused on interpretation and use of: Spoken language Written language Nonverbal language.

68. Specific Nursing Actions First identify the methods the client can use to communicate his/her basic needs: Pointing or other hand signals and pantomime Eye blinks or head nods Writing or drawing

69. Specific Nursing Actions Create a therapeutic environment Convey respect and willingness to understand Minimize outside distractions Maintain eye contact (the eyes are the window to the soul) Be aware of body language (both yours and the client’s) Use touch to create a sense of connection touch will also send nerve stimulation to boost neuron regeneration

70. Tips to Promote Communication and Comprehension Speak slowly, in short phrases in a normal tone of voice Allow person time to respond—do not interrupt and supply words only occasionally Rephrase to validate what was said (or pantomimed) Do not pretend to understand if you don’t Acknowledge the client’s frustration

71. Tips to Promote Communication and Comprehension Remember repetition aids in building new neuronal pathways: Repeat or rephrase requests Try to use the same words with the same task (i.e. bathroom vs. toilet, pill vs. medication) Keep a record at the bedside of the words to maintain continuity Write key words on flashcards for patient practice

72. Final Communication Tips

73. Practical Application Now that you have learned tips to communicate with aphasic individuals it is time to put this information into practice. Let’s look at some case studies.

74. Hedy is a 34yo female who sustained a head injury yesterday in a motor vehicle accident. A CT scan done on admission showed a controlled bleed in the temporal lobe. When you meet her this AM she is awake but responds to your greeting with a confused look followed by a long, complicated sentence filled with nonsense words.

75. Your initial assessment reveals normal vital signs, but a decreased pO2 of 86%. Your first action will be to re-insert her oxygen cannula (which she has pushed up onto her forehead) and adjust the flow to 4l/m. Neurological assessment findings: PERLA with spontaneous eye opening Motor response is maximal with good movement of all extremities Verbal response remains garbled although her pO2 is now 98%

76. As you record your findings on her chart, you note her diagnosis: “Acute head injury, complicated by aphasia” Based on your assessment and her injury, which type of aphasia does Ms. Ache have?

77. SORRY—you are incorrect. Ms. Ache is presenting signs of Wernicke’s aphasia. Broca’s area in located in the frontal lobe—Ms Ache’s injury is in the temporal lobe. Broca’s aphasia is characterized by short, incomplete sentences. Hedy’s speech is fluent, but incomprehensible.

78. YES—you are correct Hedy’s injury is in her temporal lobe, the location of Wernicke’s area Wernicke’s aphasia is characterized by fluent but nonsensical sentences. The individual may appear confused although intelligence is normal.

79. Choose which method of communication you feel will be most effective for Ms. Ache: Verbal Written Gestures and pantomime

80. Mr. S. Troke is a 68yo male admitted 3 days ago following an ischemic cerebral vascular accident (CVA) in his left frontal lobe. His chart states his recovery has been without complications, but slow. Nurse’s notes indicate that Mr. Troke is “withdrawn” and “non-compliant” with his therapies.

81. Your initial assessment findings are: Vital signs within normal range for Mr. T. Eye opening spontaneously Verbal response delayed but appropriate Motor response shows right side is weaker than his left side Mr. Troke responds to your questions in slow and choppy sentences, leaving out many words.

82. Mr. Troke is exhibiting symptoms of which type of aphasia syndrome? Broca’s Conduction Transcortical Wernicke’s

83. Mr. Troke’s CVA occurred in his frontal lobe---the location of Broca’s area. Individuals with injury in the frontal lobe will often exhibit right-sided weakness as the frontal lobe is also important for control of body movement.

84. Choose the 3 best indicators of Broca’s aphasia syndrome: Speech is fluent with long, flowing sentences Speech is slow and labored, without intonation Repetition of the same words is frequent Individual will often use neologisms (made up words) Individual is aware of his language deficits

85. Mr. Troke’s “non-compliance” may be linked to : Confusion Stubbornness Depression

86. Because individuals with Broca’s aphasia are aware of their deficits, they are often frustrated and depressed. Mr. Troke would benefit from interactions with nurses who take time to patiently establish a caring connection. Remember: active listening and therapeutic touch are as important a healthcare tool as your stethoscope!

87. Summary Aphasia is a symptom of a disturbance to the brain’s neuronal communication pathways. These pathways CAN be reconstructed with repeated appropriate cognitive stimulation. Nurses have a key role in assisting aphasic individuals to regain communication skills.

88. When Communication Breaks Down: Try saying it in a different way. Try writing it down or drawing it. Take time to really listen. Avoid interrupting or correcting the individual's speech. Encourage any type of communication, whether it is speech, gesture, pointing, or drawing. Celebrate any successes!

89. Remember: Communication is one of the most powerful gifts given to us as human beings.

90. Resources Ackerman, S. (1992). Discovering the brain. Washington DC: National Academy of Sciences. Aphasia. (2007, March 2). In Wikipedia, The Free Encyclopedia. Retrieved March 5, 2007, from http://en.wikipedia.org/wiki/Aphasia Bhogal, S.; Teasell, R.; Speechley, M. (2003). Intensity of aphasia therapy, impact on recovery. Stroke. 34:987. Retrieved March 15, 2007 from http://stroke.ahajournals.org/cgi/content/full/ Bowne, P.S., (2004-2005). PATHO Physiology Tutorials. Retrieved April 21, 2007 from http://faculty.alverno.edu/bowneps/index.html Carpentio, L. (1993). Nursing diagnosis. Application to clinical practice (5th edition). Philadelphia, PA: J.B. Lippincott Company. Hallett, M. (2005). Guest editorial. Neuroplasticity and rehabilitation. Journal of Rehabilitation Research & Development, 42(4), xvii-xxi. Retrieved April 17, 2007 from the CINAHL Plus with Full Text database at http://0-web.ebscohost.com.topcat.switchinc.org/--cinahl. Jacobs, D. (2005, December,5). Aphasia. Retrieved February 21, 2007 from http://www.emedicine.com/NEURO/topic437.htm Johnson, G. (1998). Understanding how the brain works. Traumatic brain injury survival guide. Retrieved February 21, 2007 from http://www.tbiguide.com/howbrainworks.html.

91. Resources Johnson, L. (2007). For better or for worse. Retrieved February 12, 2007 from web site: http://www.fborfw.com/strip_fix/ Markus, Hugh (2001, October). The pathophysiology of stroke. The British journal of cardiology. 8 (10): 586-9. Retrieved March 12, 2007 from www.basp.ac.uk. Microsoft (2003). Animation and clipart. Moorhead, S., Johnson, M., and Maas, M. (Eds.). (2004). Nursing outcomes classification (NOC) (3rd ed.). St. Louis, MO: Mosby Elsevier. National Institute on Drug Abuse. Image retrieved March 12, 2007 from http://www.nida.nih.gov/JSP/MOD3/page3.html National Institutes of Health 92007). Brain image retrieved February 12, 2007 from http://www.answers.com/topic/national-institutes-of-health Nordehn, G., Meredith, A., & Bye, L. (2006). Grand rounds. A preliminary investigation of barriers to achieving patient-centered communication with patients who have stroke-related communication disorders. Topics in stroke rehabilitation, 13 (1), 68-77. Retrieved April 17, 2007 from the CINAHL Plus with Full Text database at http://0-web.ebscohost.com.topcat.switchinc.org/-- cinahl Porth, C. (2004). Essentials of pathophysiology: Concepts of altered health states. Philadelphia, PA: Lipincott Williams & Wilkins. Purdy, Michael (2007, March 14). Stroke damage keeps brain regions from “talking” to each other. Retrieved March 21, 2007 from http://www.eurekalert.org/pub_releases/2007.

92. Resources Restak, Richard. (1995). Brainscapes., New York, NY: Hyperion. Sundin, K., Jansson, L., & Norberg, A. (July, 2000). Communicating with people with stroke and aphasia: understanding through sensation without words. Journal of Clinical Nursing, 9 (4), 481-488. Retrieved March 16, 2007 from the CINAHL Plus with Full Text database at http://0-web.ebscohost.com.topcat.switchinc.org/--cinahl Sundin, K., Jansson, L., & Norberg, A. (2002) Understanding between care providers and patients with stroke and aphasia: a phenomenological hermeneutic inquiry. Nursing Inquiry, 9 (2), 93-103. Retrieved March 16, 2007 from the CINAHL Plus with Full Text database at http://0-web.ebscohost.com.topcat.switchinc.org/--cinahl Ward, Jamie (2006). Introducing Cognitive Neuroscience. Retrieved February 21, 2007 from http://www.cognitiveneuroscoencearena.com Wheeler, Mark (2006). Cellular clues identified for stroke recovery. Retrieved March 15, 2007 from http://www.eurekalert.org/pub_releases.

93. Acknowledgements Professor Pat Bowne, Alverno College for your guidance in this tutorial development and use of your pathophysiology tutorials Mary Jo Noble MSN/Ed, RN,CNOR for your guidance as clinical preceptor.