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

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Presentation on theme: "Facilitating Communication in Individuals with Neurological Disease Argye E. Hillis, MD, MA Johns Hopkins University School of Medicine."— Presentation transcript:

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

4 Stroke: Nonfluent Aphasia Facilitate comprehension 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 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 Fluent, jargon speech Well articulated; may be “empty” Well articulated; may be “empty” May use meaningless combination of English words, or use “neologisms” (made up words; e.g., splarinic) May use meaningless combination of English words, or use “neologisms” (made up words; e.g., splarinic) Often name verbs better than nouns Often name verbs better than nouns Spoken and written production are impaired Spoken and written production are impaired Poor comprehension of spoken and written words Poor comprehension of spoken and written words

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

10 Stroke: Anomic Aphasia Anomia: “without names” 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 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 Model its use in communication The Visual Dictionary The Visual Dictionary

12 Communication Notebook Ex: Chapter on People Separate pages for: Separate pages for: Family Family –Mary, Karen, Betsy (sisters) –John (brother) –Dad, Mom, Grandma –Linda, Bob, Harry (cousins) Neighbors, Friends, Colleagues Neighbors, Friends, Colleagues Community: pastor, maid, barber, therapists, doctors, Community: pastor, maid, barber, therapists, doctors, Politicians, actors, actresses, atheletes 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 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 Multiple, variable off-target attempts to articulate a word Trouble with polysyllabic words Trouble with polysyllabic words Often associated with aphasia or dysarthria Often associated with aphasia or dysarthria

14 Apraxia of Speech Facilitate expression Facilitate expression Have patience! Have patience! Encourage them to write if necessary Encourage them to write if necessary Keep paper and pencil handy Keep paper and pencil handy Encourage them to try again or rephrase with shorter words 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 Spastic dysarthria: slow, reduced range of movement, harsh/strained voice quality Flaccid dysarthria: weak, breathy, hypernasal Flaccid dysarthria: weak, breathy, hypernasal Ataxia dysarthria: poor coordination of muscles of jaw, lips, tongue, palate 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 rephrase, not just repeat, if you don’t understand Ask them to speak slowly 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 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 Communication notebook may help

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

18 Stroke: Right Hemisphere Facilitate comprehension 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 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 Dysarthria: Mixed spastic and flaccid: Weakness & reduced rate and range of movements of jaw, lips, palate, tongue, vocal cords Often associated with emotional lability 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 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 rephrase, not just repeat, if you don’t understand Ask them to speak slowly 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 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 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 Always provide paper & pencil or other means to express nonverbally Consider “augmentative communication” 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 Laptop computer systems or devoted systems for communication Variety of inputs to the computer 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: 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 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 May be associated with cognitive and/or emotional problems Often associated with ataxia (poor coordination) of the limbs Often associated with ataxia (poor coordination) of the limbs

24 MS Facilitate expression: Same methods for other causes of dysarthria Facilitate expression: Same methods for other causes of dysarthria May need to weight ataxic limb with other limb to point or type May need to weight ataxic limb with other limb to point or type May take extra time to learn new system May take extra time to learn new system Show patience, desire to understand Show patience, desire to understand

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

26 Dementia Facilitate comprehension 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 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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