Think of Aphasia
About the Author
Mark Frankel, MD
Newbridge on the Charles of Hebrew SeniorLife
7000 Great Meadow Road
Dedham, MA 02026
Mark Frankel, MD is board certified in Geriatric Psychiatry and practices as a Consulting Psychiatrist.
Ms. Massari practices as a Speech and Language Pathologist.
Ms. Pender is the Team Leader for Speech and Language Pathology Services.
All of the authors are part of the professional staff at the Newbridge on the Charles campus of Hebrew SeniorLife in Dedham, MA.
Mark Frankel, MD, Carla Massari, MS, CCC-SLP, and Caitlin Pender, MA, CCC-SLP
Aphasia, the loss of ability to use language, is a common manifestation of many medical conditions found in patients for whom Aging Life Care / care management services are sought. A patient with aphasia might present as having problems using language to express themselves (expressive aphasia), as problems using language in understanding others (receptive aphasia), or both. Aphasia can range in severity from mild to severe, with corresponding degrees of impairment as a result. In a full assessment of a patient’s needs, it is important to identify and describe any aphasia and how it impacts meeting the demands of everyday life. Many times, aphasia can be harder to recognize if what brought the person to attention are the more dramatic consequences of losing social cognition such as executive dysfunction, especially impulsivity.
Aphasia can be a result of many intracranial pathologies. The most commonly recognized cause is stroke, after which aphasia manifests as much as 40% of the time. Aphasia can also be seen after traumatic brain injuries, intracranial bleeding (e.g. subdural or subarachnoid hemorrhages), infections (e.g. encephalitis, meningitis), brain tumors, or other intracranial pathologies. In cases where the onset of the underlying problem is acute and discrete, the aphasia appears just as acutely and tends to be more responsive to speech therapies, with a greater prospect for recovery or stabilization.
Aphasia can also be a result of neurodegenerative processes, ones that are more gradual and insidious in onset and progression. This includes the aphasias seen with the Dementia of Alzheimer’s Disease and its variants, Parkinsonian/Lewy Body Dementias, or Fronto-Temporal Lobar Dementias. The diagnostic criteria for a major neurocognitive disorder (colloquially, a dementia) described in DSM 5, as well as diagnostic guidelines from other sources, specifically names language impairment as a primary deficit sufficient for offering a diagnosis of a major neurocognitive disorder. It is often harder to recognize in the short term because the loss of language skills is slower and more gradual, paralleling the progression of the condition itself. In these cases the aphasia tends to respond in a more limited way to speech therapies, in part because of the general cognitive decline and in part from the inexorable progression of the underlying illness.
Although aphasia is common among patients with these conditions, it is not always recognized explicitly. Often well before Aging Life Care / care management services are sought, regular caregivers have developed routines taking care of such people, unconsciously having taken into account the loss of language skills. In the absence of language, people use behavior as a primary method of communication and regular caregivers become adept at recognizing nonverbal cues that might signal, for example, if someone is hungry or needs to use the bathroom. Recognizing these cues obviates the need for the patient to use language in asking for something they want. Similarly, caregivers often build a familiar routine around daily care such as changing clothes or bathing. Remaining within an established routine reduces the need for caregivers to explain, using language, what is taking place, or for patients to understand the language about what caregivers may be asking them to do. For this reason, establishing routine is essential for any client experiencing aphasia.
When these routines happen smoothly, and the caregiver is “filling in the blank” correctly, everything usually proceeds okay. However, there are many circumstances where it does go wrong and what could follow is an exponential increase in caregiving effort. For example, if the patient does not ask to use the bathroom and nonverbal cues are misinterpreted, it could lead to impulsive incontinence and to caregiver stress, social censure, client discomfiture, extra housekeeping burdens, and the additional ADL care that follows. Another example, if the patient does not understand what the caregiver is asking them about changing clothes before bed, it could lead to an impulsive resistance of care, with combativeness and the possibility of inadvertent injury to the patient or caregiver. In cases like these, the consequence of impulsivity and aphasia together is likely to be more substantial than the consequence of impulsivity alone. When an impulsive behavior appears dangerous, it can result in interventions to try to address the behavior, such as hospitalization or medication. Such interventions do not help in addressing the underlying deficit in communication itself.
Although there are specific disciplines trained to recognize and treat aphasia, any professional, including Aging Life Care Managers, can develop basic skills to identify which of their clients might be affected. With that recognition, patients and their families can be offered interventions specifically directed at aphasia and its consequences as part of their care plans. Consciously identifying and addressing the consequences of aphasia in all Aging Life Care / care management evaluations can make a meaningful impact in care overall.
Consciously looking for language problems can be part of any professional interaction. This might include:
- direct observation of language deficits
- awareness of one’s professional experience and behavior during the clinical encounter, and
- collateral history from caregivers about events taking place in the patient’s environment
These caregivers (including nurses, aides, and social workers) are likely to pick up subtle signs of communication problems. Speech-language pathologists and other medical professionals typically combine their clinical examinations with such reports from a patient’s caregiver in their assessments.
Aphasia can present as both verbal and written impairments. With auditory comprehension impairment, a patient may have difficulty understanding verbally presented directions, manifesting most with multi-step commands and long sentences. With comprehension impairment of written language (e.g. agrammatism, alexia), a patient may have difficulty reading, manifesting as difficulty with books, menus, and calendars. With expressive impairment of written language, a patient may have difficulty with writing, manifesting as difficulty signing their name or writing personal information (e.g. completing medical forms/documents). With expressive language impairment of spoken language, a patient may have difficulty:
- naming objects or coming up with the word they want to use
- pronouncing words clearly, resulting in word or sound substitutions (e.g. “chair” for “table” or “might” for “fight”)
- offering independent ideas spontaneously, as opposed to repeating what they hear or using rote phrases (e.g. “I love you”, “Get away!”)
- answering open ended questions
- making and expressing choices
- constructing their wants or ideas in an organized way.
More subtle signs and symptoms of aphasia may include frustration with communication attempts, withdrawal from communicative situations, social isolation, and appearing to have a depression.
A professional can also use an awareness of their own experience during a professional encounter as clues to a possible aphasia. In social interactions with inherent difficulty in communication, for example a language barrier, people often change the way they speak. This typically includes some combination of speaking more slowly, more loudly, more simply with vocabulary and syntax, and using accompanying gestures. A professional, noticing they are doing so during a clinical encounter, should be cued to suspect that the patient may have an aphasia. Similarly with older patients who may be hard of hearing, a professional should not automatically attribute difficulty in communication to the hearing problem, rather allow for the possibility of a co-morbid aphasia.
Collateral history from caregivers is invaluable in identifying language problems. Patients with aphasia learn to accommodate for their impairments, developing strategies for minimizing everyday communication burdens. They might participate only passively in whatever discussion is taking place. They might try to avoid interaction with others, especially where conversation is taking place. They might be overly affectionate and reliant on gesture to maintain attention of the people they want. They might always defer to a default option, for example when presented with a dinner choice of several options, a response of “I’ll take the chicken” or “I’ll have the special” takes the pressure off generating language. Asking caregivers about such events might lead to clues about a possible aphasia.
If a professional identifies a patient with language impairment, a referral to a speech-language pathologist for a comprehensive communication evaluation can be sought. A patient can gain the most benefit from language treatment when their other cognitive skills remain functional enough to demonstrate insight into the communication deficit, to maintain a motivation to participate in therapy, and to utilize compensatory techniques during communication interactions. Circumstances when speech language pathology services can markedly beneficial include recovery after an acute neurological event such as a stroke or traumatic/non traumatic brain injury. Speech language pathology services may not be as beneficial if the language disorder is part of an ongoing neurodegenerative process. Additionally, individual goals of care should be taken into consideration. If those goals of care are focused on maintenance or palliation, as opposed to intensive therapy, a limited approach can be used, for example emphasizing only environmental or adaptive modifications.
If a full comprehensive speech language pathology assessment is indicated, such an evaluation will include assessment of all domains of language (receptive, expressive, reading, and writing), speech production, and cognitive/social features of communication. Based on this assessment, a speech-language pathologist can identify the type and severity of aphasia, communication strengths and weaknesses, and the impact on the patient (e.g. quality of life, daily activities and care, social situations).
Once a patient is identified with aphasia, a speech-language pathologist can develop an individualized treatment plan to address the language goals important to that patient. Common treatment goals include remediation of specific language domains, teaching compensatory techniques to maximize communication skills, and teaching strategies to the patient and their care team ways to communicate more effectively. Overall, the primary goal is to help the person with aphasia communicate using language over behavior.
There are two primary types of communication strategies: internal communication strategies and environmental/adaptive strategies. Internal communication strategies focus on what the patient can do themselves in using language. A patient with aphasia may be able to use internal communication strategies in different combinations, with variable levels of support. Examples of internal communication strategies include:
- thinking/generating ideas before speaking
- using circumlocution (describing a word or situation that a person may have difficulty generating)
- word finding strategies (using a description or synonym to replace the word the patient is having difficulty generating)
- setting the topic to make sure the listener knows the context of your message
- using multi-modal communication (i.e. using gesture, pointing, drawings, and facial expressions to supplement verbal expression).
A patient with aphasia may also be a candidate for an augmentative or alternative communication (AAC) device, which can be low tech or high tech. A low tech AAC device may be a picture board. The patient can express basic wants and needs by selecting a word or picture. There are also high tech AAC devices, like a computer based speech generating device, where a patient may select target icons to generate words, phrases, and sentences to express wants, needs, and ideas.
Environmental/adaptive strategies may also help facilitate communication and focus on what can be done around the patient. Examples of environmental/adaptive strategies a caregiver can utilize include:
- reducing environmental distractions while speaking, making sure the surroundings are quiet
- looking directly at your communication partner face to face to pick up on non-verbal cues like facial expressions, gestures, and body language
- speaking at a normal volume; being louder will not help
- speaking slowly and with simple language, using phrases and short sentences when possible, one statement at a time
- allowing time to respond, giving the patient the longer time they need to generate their thoughts and ideas
- asking yes/no questions or choice questions versus open ended questions (i.e. “Do you want cereal or eggs for breakfast?” versus “What do you want for breakfast?”)
- encouraging participation in social activities when appropriate
- not pretending to understand what the patient has said when you do not. Instead, repeat back what you did understand and/or ask for clarification and repetition.
Teaching and reinforcing communication strategies with a patient’s caregivers is essential in maintaining the consistency of a communication approach. It is helpful to have and display a written reference of communication techniques and environmental strategies where the patient happens to be (e.g. at home, during hospitalizations). Learning these communication tools should be part of any caregiver’s introduction to the patient and encouraging caregivers to review these tools should be part of the supervision of caregivers. Where caregivers regularly change, this can be a challenge to delivering consistency of a communication approach. In such cases, someone from the team, such as a regular nurse or care manager, should be more proactive about offering education regarding the personalized strategies. Developing these written references for personalized strategies can be part of the services of a speech language pathologist. Additionally, the American Speech-Language and Hearing Association (ASHA) is an excellent resource of information about aphasia for caregivers and families.
Conducting any kind of professional assessment starts with discovering what the problem is which led to the referral. A professional assessment does not simply end with a superficial solution to the presenting problem, rather it includes identifying the underlying causes. Addressing these causes can provide a more stable and durable solution for the presenting problem itself. Many of the dramatic causes that lead to care management referrals, such as being unsafe at home or being aggressive with caregivers, have language impairment as a proximate cause. A more sophisticated assessment would take that possibility into account, starting with careful attention to how a patient uses language during the assessment.
Language in its complexity is among the most powerful achievements of humanity. Using it allows the communication of ideas. It allows people to share with one another ideas about internal states (like how someone is feeling or felt), ideas through time (like a recipe for beer among hieroglyphs in a pharaoh’s tomb from 5000 years ago), or ideas across space (like how aphasia might be impacting patients’ daily needs in 2017). When illness robs people of the ability to use language is it among the most tragic losses. Finding a way to intervene in the hope of stabilizing such losses might be an invaluable part of a care plan. It starts with recognizing that someone may have an aphasia. It continues with studying and describing the impact on their life. It leads to developing communication strategies to compensate and teaching them to the patient’s caregiving system. Care Mangers that understand how to recognize, intervene and reinforce care plan strategies over time, can potentially make significant improvements to both client and caregivers’ quality of life.