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 (Broca’s) Aphasia • Telegraphic speech: content words • Agrammatic • Nouns named better than verbs • Spoken and written sentence production are impaired • Poor spelling (especially verbs) • Relatively good comprehension • May have trouble with syntactically complex sentences, passive voice sentences

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 (Wernicke’s) Aphasia • Facilitate comprehension • Provide gestures, pictures, context • Speak in short, complete sentences • Pause between sentences • Avoid low familiarity words • Rephrase sentences in a different way • After “We will be going to the shopping center in a few minutes” • “We are leaving for the mall soon”

8. Stroke: Wernicke’s Aphasia • Facilitate expression • If you don’t understand, say so apologetically (& shake your head) • Provide choices, with pictures/gestures • Do you want: • Chicken? • Fish? • Steak? • Ask him/her to point, then say the word • Encourage gestures, drawing, pointing • Model their use for communication

9. Stroke: Wernicke’s Aphasia • Try a communication notebook with words and pictures • Organize by theme • Family, pets, activities, places • Have him/her select items to include • Model its use in communication • Higher tech augmentative communication devices require more training

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-> “cork” or “hork” • Fort-> “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 don’t understand • Ask them to speak slowly • Ask them to point to the first letter of each word on an alphabet board, or write the first letter of each word, as they speak • Slows them down • Provides additional information • Communication notebook may help

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 – don’t rely on facial expressions & gestures • Facilitate expression • Ask him or her to tell you his/her emotions

19. ALS: Lou Gherig’s Disease • Dysarthria: Mixed spastic and flaccid: Weakness & reduced rate and range of movements of jaw, lips, palate, tongue, vocal cords • Often associated with emotional lability • Laughter & crying out of proportion to emotion • Can be associated with frontotemporal dementia: asymmetric atrophy of the frontal and temporal lobes

20. ALS: Facilitate expression • Ask them to rephrase, not just repeat, if you don’t understand • Ask them to speak slowly • Ask them to point to the first letter of each word on an alphabet board, or write the first letter of each word, as they speak • Try occluding nose to reduce escape of air • Palatal lift may help

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 • Alzheimer’s Disease • Progressive decline in memory • Progressive decline in at least one other domain of communication • Vascular Dementia (due to strokes) • Frontotemporal Lobar Degeneration • Dysexecutive syndrome (right frontal or temporal) • Progressive, Nonfluent aphasia – left frontal form • Semantic Dementia – left temporal form

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)