Facilitating Facilitating Communication in Communication in

Individuals with Individuals with Neurological DiseaseNeurological Disease

Argye E. Hillis, MD, MAArgye E. Hillis, MD, MA

Johns Hopkins University Johns Hopkins University School of MedicineSchool of Medicine

Stroke: Aphasia,Stroke: Aphasia,Apraxia of Speech &/or Apraxia of Speech &/or

DysarthriaDysarthria Aphasia: Impaired languageAphasia: Impaired language

– Symbolic communicationSymbolic communication– Words, grammarWords, grammar– Comprehension and/or production of language Comprehension and/or production of language

are impairedare impaired– Verbal and/or written communication (reading Verbal and/or written communication (reading

and/or writing) are impairedand/or writing) are impaired Apraxia of speech: motor planning and Apraxia of speech: motor planning and

programming of speech articulationprogramming of speech articulation Dysarthria: Impaired motor speech due to Dysarthria: Impaired motor speech due to

weakness, impaired coordination, reduced weakness, impaired coordination, reduced rate or range of movement of jaw, lips, rate or range of movement of jaw, lips, tongue, palate, vocal cords, respiratory tongue, palate, vocal cords, respiratory musclesmuscles

Nonfluent (Broca’s) AphasiaNonfluent (Broca’s) Aphasia Telegraphic speech: content wordsTelegraphic speech: content words AgrammaticAgrammatic Nouns named better than verbsNouns named better than verbs Spoken and written sentence Spoken and written sentence

production are impairedproduction are impaired Poor spelling (especially verbs)Poor spelling (especially verbs) Relatively good comprehensionRelatively good comprehension

– May have trouble with syntactically May have trouble with syntactically complex sentences, passive voice complex sentences, passive voice sentencessentences

Stroke: Nonfluent AphasiaStroke: Nonfluent Aphasia

Facilitate comprehensionFacilitate comprehension– Speak in short, complete sentencesSpeak in short, complete sentences– Simplify grammatical structure:Simplify grammatical structure:– Avoid passive voice Avoid passive voice

Instead of: Linda was kicked by the boy.Instead of: Linda was kicked by the boy. The boy kicked Linda.The boy kicked Linda.

– Avoid before/after, in front of/ behindAvoid before/after, in front of/ behind Instead of: Please sign the form after you Instead of: Please sign the form after you

have read ithave read it Please read the form. Then sign it.Please read the form. Then sign it.

Stroke: Nonfluent AphasiaStroke: Nonfluent Aphasia Facilitate verbal expressionFacilitate verbal expression

– Provide choices for answersProvide choices for answers– Instead of: What do you want for dinner?Instead of: What do you want for dinner?– Do you want chicken, steak, or fish?Do you want chicken, steak, or fish?

Chicken? Steak? Fish?Chicken? Steak? Fish? Or written choicesOr written choices

– If you think you know the possible word If you think you know the possible word being attempted, provide the first soundbeing attempted, provide the first sound For fish, say /f/For fish, say /f/

– Or provide written words – may cue Or provide written words – may cue them to say the word correctlythem to say the word correctly

Stroke: Fluent (Wernicke) Stroke: Fluent (Wernicke) AphasiaAphasia

Fluent, jargon speechFluent, jargon speech Well articulated; may be “empty”Well articulated; may be “empty” May use meaningless combination of May use meaningless combination of

English words, or use “neologisms” English words, or use “neologisms” (made up words; e.g., splarinic)(made up words; e.g., splarinic)

Often name verbs better than nounsOften name verbs better than nouns Spoken and written production are Spoken and written production are

impairedimpaired Poor comprehension of spoken and Poor comprehension of spoken and

written wordswritten words

Stroke: Stroke: Fluent (Wernicke’s) AphasiaFluent (Wernicke’s) Aphasia

Facilitate comprehensionFacilitate comprehension– Provide gestures, pictures, contextProvide gestures, pictures, context– Speak in short, complete sentencesSpeak in short, complete sentences– Pause between sentencesPause between sentences– Avoid low familiarity wordsAvoid low familiarity words– Rephrase sentences in a different wayRephrase sentences in a different way

After “We will be going to the shopping After “We will be going to the shopping center in a few minutes”center in a few minutes”

““We are leaving for the mall soon” We are leaving for the mall soon”

Stroke: Wernicke’s AphasiaStroke: Wernicke’s Aphasia

Facilitate expressionFacilitate expression– If you don’t understand, say so If you don’t understand, say so

apologetically (& shake your head)apologetically (& shake your head)– Provide choices, with pictures/gesturesProvide choices, with pictures/gestures– Do you want:Do you want:

Chicken?Chicken? Fish?Fish? Steak?Steak?

– Ask him/her to point, then say the wordAsk him/her to point, then say the word– Encourage gestures, drawing, pointingEncourage gestures, drawing, pointing

Model their use for communicationModel their use for communication

Stroke: Wernicke’s AphasiaStroke: Wernicke’s Aphasia

Try a communication notebook with Try a communication notebook with words and pictureswords and pictures

Organize by themeOrganize by theme– Family, pets, activities, placesFamily, pets, activities, places

Have him/her select items to includeHave him/her select items to include Model its use in communicationModel its use in communication Higher tech augmentative Higher tech augmentative

communication devices require more communication devices require more trainingtraining

Stroke: Anomic AphasiaStroke: Anomic Aphasia

Anomia: “without names”Anomia: “without names”– Poor word findingPoor word finding– Tip of the tongue phenomenonTip of the tongue phenomenon– Nouns often disproportionately affectedNouns often disproportionately affected– Produce circumlocutions (e.g., for fork: “the Produce circumlocutions (e.g., for fork: “the

thing you use to eat, to stab with, like for thing you use to eat, to stab with, like for vegetables)vegetables)

– May produce paraphasias (word May produce paraphasias (word substitutions)substitutions) Fork-> “cork” or “hork”Fork-> “cork” or “hork” Fort-> “spoon”Fort-> “spoon”

Stroke: Anomic AphasiaStroke: Anomic Aphasia

Provide a communication notebook Provide a communication notebook with written wordswith written words– Pocket size is bestPocket size is best– Organize into “chapters” with themesOrganize into “chapters” with themes

People (friends, family, staff, famous people)People (friends, family, staff, famous people) Activities (responsibilities, hobbies, ADLs)Activities (responsibilities, hobbies, ADLs)

– Have him or her choose the items to Have him or her choose the items to includeinclude

– Add items frequently (leave room)Add items frequently (leave room) Model its use in communicationModel its use in communication The Visual DictionaryThe Visual Dictionary

Communication NotebookCommunication NotebookEx: Chapter on PeopleEx: Chapter on People

Separate pages for:Separate pages for: FamilyFamily

– Mary, Karen, Betsy (sisters)Mary, Karen, Betsy (sisters)– John (brother)John (brother)– Dad, Mom, GrandmaDad, Mom, Grandma– Linda, Bob, Harry (cousins)Linda, Bob, Harry (cousins)

Neighbors, Friends, ColleaguesNeighbors, Friends, Colleagues Community: pastor, maid, barber, Community: pastor, maid, barber,

therapists, doctors, therapists, doctors, Politicians, actors, actresses, atheletesPoliticians, actors, actresses, atheletes

– Whatever they like to talk aboutWhatever they like to talk about

Apraxia of SpeechApraxia of Speech

Impaired planning and programming Impaired planning and programming of speech articulation, that cannot be of speech articulation, that cannot be explained by weakness, impaired explained by weakness, impaired coordination, or reduced rate or range coordination, or reduced rate or range of movements of the muscles of the of movements of the muscles of the jaw, lips, palate, tongue, vocal cordsjaw, lips, palate, tongue, vocal cords

Multiple, variable off-target attempts Multiple, variable off-target attempts to articulate a wordto articulate a word

Trouble with polysyllabic wordsTrouble with polysyllabic words Often associated with aphasia or Often associated with aphasia or

dysarthriadysarthria

Apraxia of SpeechApraxia of Speech

Facilitate expressionFacilitate expression Have patience!Have patience! Encourage them to write if necessaryEncourage them to write if necessary Keep paper and pencil handyKeep paper and pencil handy Encourage them to try again or Encourage them to try again or

rephrase with shorter wordsrephrase with shorter words

Brainstem or Bilateral Stroke: Brainstem or Bilateral Stroke: Dysarthria Dysarthria

Spastic dysarthria: slow, reduced Spastic dysarthria: slow, reduced range of movement, harsh/strained range of movement, harsh/strained voice qualityvoice quality

Flaccid dysarthria: weak, breathy, Flaccid dysarthria: weak, breathy, hypernasalhypernasal

Ataxia dysarthria: poor coordination of Ataxia dysarthria: poor coordination of muscles of jaw, lips, tongue, palatemuscles of jaw, lips, tongue, palate– Inappropriate pitch changes, hyper/ Inappropriate pitch changes, hyper/

hyponasality, slow to compensatehyponasality, slow to compensate– Trouble with consonant blends (e.g, Trouble with consonant blends (e.g,

splash, flasks)splash, flasks)

Dysarthria: Facilitate Dysarthria: Facilitate expressionexpression

Ask them to rephrase, not just Ask them to rephrase, not just repeat, if you don’t understandrepeat, if you don’t understand

Ask them to speak slowlyAsk them to speak slowly Ask them to point to the first letter of Ask them to point to the first letter of

each word on an alphabet board, or each word on an alphabet board, or write the first letter of each word, as write the first letter of each word, as they speakthey speak– Slows them downSlows them down– Provides additional informationProvides additional information

Communication notebook may helpCommunication notebook may help

Stroke: Right HemisphereStroke: Right Hemisphere

Trouble with abstract languageTrouble with abstract language– MetaphorsMetaphors– AnalogiesAnalogies– ProverbsProverbs– JokesJokes

Trouble understanding vocal Trouble understanding vocal intonation, facial expression, gesturesintonation, facial expression, gestures

Limited intonation, facial expression, Limited intonation, facial expression, gestures gestures

Stroke: Right HemisphereStroke: Right Hemisphere

Facilitate comprehensionFacilitate comprehension– Avoid metaphor Avoid metaphor

e.g., He kept her on a pedestal.e.g., He kept her on a pedestal.

– Avoid sarcasm! (it may be taken literally)Avoid sarcasm! (it may be taken literally)– Convey meaning and emotion with words – Convey meaning and emotion with words –

don’t rely on facial expressions & gesturesdon’t rely on facial expressions & gestures Facilitate expressionFacilitate expression

– Ask him or her to tell you his/her emotionsAsk him or her to tell you his/her emotions

ALS: Lou Gherig’s Disease ALS: Lou Gherig’s Disease

Dysarthria: Mixed spastic and flaccid: Dysarthria: Mixed spastic and flaccid: Weakness & reduced rate and range of Weakness & reduced rate and range of movements of jaw, lips, palate, tongue, movements of jaw, lips, palate, tongue, vocal cordsvocal cords

Often associated with emotional labilityOften associated with emotional lability– Laughter & crying out of proportion to emotion Laughter & crying out of proportion to emotion

Can be associated with frontotemporal Can be associated with frontotemporal dementia: asymmetric atrophy of the dementia: asymmetric atrophy of the frontal and temporal lobesfrontal and temporal lobes

ALS: Facilitate expressionALS: Facilitate expression

Ask them to rephrase, not just Ask them to rephrase, not just repeat, if you don’t understandrepeat, if you don’t understand

Ask them to speak slowlyAsk them to speak slowly Ask them to point to the first letter of Ask them to point to the first letter of

each word on an alphabet board, or each word on an alphabet board, or write the first letter of each word, as write the first letter of each word, as they speakthey speak

Try occluding nose to reduce escape Try occluding nose to reduce escape of airof air– Palatal lift may helpPalatal lift may help

Bulbar ALS or Brainstem Stroke Bulbar ALS or Brainstem Stroke with Inability to Speakwith Inability to Speak

Always provide paper & pencil or Always provide paper & pencil or other means to express nonverballyother means to express nonverbally

Consider “augmentative Consider “augmentative communication”communication”– Low tech: Low tech:

Communication notebook: words/phrasesCommunication notebook: words/phrases Alphabet board: May be Alphabet board: May be

plexiglass/transparent to allow them to plexiglass/transparent to allow them to select letters with eyes, in such a way that select letters with eyes, in such a way that “listener” can detect their selection“listener” can detect their selection

Augmentative Communication: High Augmentative Communication: High TechTech

Laptop computer systems or devoted Laptop computer systems or devoted systems for communicationsystems for communication

Variety of inputs to the computerVariety of inputs to the computer– May rely on just eye movements, sip/puff, joy May rely on just eye movements, sip/puff, joy

stick, any reliable movementstick, any reliable movement– Row/column scanning, morse code, direct Row/column scanning, morse code, direct

selection (best)selection (best) Output: Output:

– Print (good for permanent record)Print (good for permanent record)– Verbal (important for phone, audiences)Verbal (important for phone, audiences)

stored words/phrases, synthesized/digitized speech stored words/phrases, synthesized/digitized speech Pizza – Peetsa Pizza – Peetsa

Multiple Sclerosis: MSMultiple Sclerosis: MS

Dysarthria: mixed ataxic and spasticDysarthria: mixed ataxic and spastic– Ataxic: Poor coordination of the jaw, lips, Ataxic: Poor coordination of the jaw, lips,

palate, tonguepalate, tongue– Spastic: slow, reduced range of Spastic: slow, reduced range of

movementmovement May be associated with cognitive May be associated with cognitive

and/or emotional problemsand/or emotional problems Often associated with ataxia (poor Often associated with ataxia (poor

coordination) of the limbscoordination) of the limbs

MSMS

Facilitate expression: Same methods Facilitate expression: Same methods for other causes of dysarthriafor other causes of dysarthria

May need to weight ataxic limb with May need to weight ataxic limb with other limb to point or typeother limb to point or type

May take extra time to learn new May take extra time to learn new systemsystem

Show patience, desire to understandShow patience, desire to understand

DementiaDementia

Alzheimer’s DiseaseAlzheimer’s Disease– Progressive decline in memoryProgressive decline in memory– Progressive decline in at least one other domain Progressive decline in at least one other domain

of communicationof communication Vascular Dementia (due to strokes)Vascular Dementia (due to strokes) Frontotemporal Lobar DegenerationFrontotemporal Lobar Degeneration

– Dysexecutive syndrome (right frontal or Dysexecutive syndrome (right frontal or temporal) temporal)

– Progressive, Nonfluent aphasia – left frontal formProgressive, Nonfluent aphasia – left frontal form– Semantic Dementia – left temporal formSemantic Dementia – left temporal form

DementiaDementia

Facilitate comprehensionFacilitate comprehension– Speak in short, complete sentencesSpeak in short, complete sentences– Repeat frequentlyRepeat frequently– Write in short, complete sentencesWrite in short, complete sentences

Reminders regarding where loved ones are & Reminders regarding where loved ones are & when they will return, what they need to do when they will return, what they need to do (e.g., take medications – specify what and (e.g., take medications – specify what and when)when)

Make copies, put them everywhereMake copies, put them everywhere

– Use familiar, high frequency wordsUse familiar, high frequency words– Avoid abstract languageAvoid abstract language– Use gestures, drawings, pictures if neededUse gestures, drawings, pictures if needed

DementiaDementia

Facilitate productionFacilitate production– Ask open-ended questionsAsk open-ended questions– Show patience when they speakShow patience when they speak– Communication notebook, especially with Communication notebook, especially with

names of people, places, and events may names of people, places, and events may help them recall words they want to usehelp them recall words they want to use

– Include calendar, mark off days as they Include calendar, mark off days as they go by, mark future events, appointments go by, mark future events, appointments (yours and theirs), responsibilities (e.g. (yours and theirs), responsibilities (e.g. take out trash) take out trash)