Vol. 23 Issue 3
Health care professionals need to keep current on this language impairment
Aphasia is a condition that inhibits one's ability to speak and pronounce words correctly. However, the real communication barriers, according to experts in the field, may involve those on the receiving end. This includes health care professionals responsible for providing care and rehabilitation services to this patient population.
"I don't think all health care practitioners truly understand the nuances of this condition," said Mary Purdy, PhD, CCC-SLP, a certified speech-language pathologist who specializes in aphasia treatment. "The problems with aphasia are really quite different than many people perceive."
Described by the National Aphasia Association as a language impairment that affects speech production or comprehension, aphasia is most often brought on by a stroke that damages the left hemisphere, the "language center" of the brain. It also can occur due to head trauma, brain tumor or infection.
One of the common misconceptions about aphasia, Purdy said, is that people with the disorder suffer a loss of intelligence. On the contrary, patients with aphasia typically know what is going on around them and know exactly what they want to say, but they cannot express their thoughts into actual, sensible words.
"It's like being a tourist in a foreign country who wants to say, 'Where can I get something to eat,' but doesn't know how to say the native word for 'restaurant,'" said Purdy, who's also associate professor of communication disorders at Southern Connecticut State University in New Haven.
But the confusion regarding this condition, which currently affects about 1 million Americans, doesn't end there.
Setting Things Straight
One of the more troubling fallacies surrounding aphasia is the belief that people can be born with it, Purdy said.
"There is some controversy as to whether children have it, but research has shown it's not something you're born with," she explained. "It's an acquired problem that arises because of brain damage after birth. Childhood aphasia is not a developmental problem, either. It's generally only diagnosed if the child had developed normal language and then had a stroke or head injury."
Other falsehoods are that aphasic patients only have trouble communicating words, and that they only have a limited time in which they can recover.
"It's not just an expressive problem, it's a receptive problem too," said Jan Pierson, LPN, a staff nurse at Bryn Mawr Rehab Hospital in Malvern, PA. "These patients are having trouble making sense of what we say to them as well."
Depending on the type of aphasia (Sidebar), persons can experience varying ranges of complications related to speaking, reading and writing. The length of time it takes to regain normalcy depends on the severity (or density) of the aphasia, determined by the location and degree of the individual's stroke or brain injury. Aphasia is not always completely reversible, Purdy said.
"If somebody has a stroke that affects many areas of the brain where language is supported, they're going to have a more dense aphasia," she continued. "They may have no verbal output or not be able to understand spoken words. Those who have strokes that are away from that area may have more subtle problems. They may be able to have conversations or read, but may still have word retrieval problems or difficulty reading a novel as opposed to a magazine article. There's a huge range of aphasia severity.
"Any [health care provider] who works in an acute care or a rehab hospital with neurological patients or, in some cases, long-term care, is very likely to encounter these patients and should really know there are many misconceptions out there about this condition," Purdy added.
And, while aphasic patients in LTC may be dually diagnosed with dementia or other conditions that require skilled care, aphasia is not related to dementia, she said.
"I think that's the most common misconception," Purdy continued. "There's a belief that those with the condition are not competent–that they can't make medical decisions or deal with everyday situations."
Aphasic patients often have problems with swallowing as well, said Pierson. "Their brains can't handle that 'stop, swallow' command. They often have to eat ground or pureed food."
Swallowing liquids is especially difficult for aphasic patients, Pierson added. "They can't drink 'regular' waterit goes down their throat too fast," she continued. "We have thickened water from the dietary department that we administer to them."
Depending on the severity of their conditions, this "water" can be as thick as honey, Pierson said. "It's not the most pleasant-tasting thing," she admitted. "I tasted it to get a better understanding of what they're dealing with, and I didn't like it."
In light of the confusion and inherent communication barriers associated with this condition, Purdy and Pierson suggest collaborating with your facility's speech therapy staff as a resource.
"Take the opportunity to work together," said Purdy, who collaborates frequently in her role as a speech pathologist consultant at Eastern Rehabilitation Network, Newington, CT, and Hartford Hospital. "With the right approach and attempts from health care professionals, individuals [with aphasia] can demonstrate competency and make recoveries."
That recovery, Purdy said, should start with health care providers working together to facilitate communication through what she calls "multi-modality techniques," such as using hand gestures when speaking, pointing to things in the patient's environment they may need or want to use (such as the bathroom) and, for those patients who can read, writing down key words and having the patient point to the ones that express their thoughts.
"You usually have to be patient and keep asking them questions until you know what they need," she said. "However, you shouldn't bombard patients with questions; give them time to respond, and provide other response options, like pointing to a written word."
Purdy also encourages allowing these patients to meet in groups, so they can see that there are others experiencing the same difficulties.
Progress in these patients may be subtle when judged day-by-day, Purdy said, but in the long run, can be quite noticeable.
"You can pick up on a patient's progress by observing him talk more or by -realizing that you are using fewer gestures to communicate with him," she explained. "The patient may slow down from week-to-week or month-to-month, but you may see improvements in certain situations –like when he starts answering a phone or begins asking when breakfast will be served."
Pierson said the progress these patients make can be more dramatic when compared to surgical patients because of the struggles they endure throughout.
"It's a totally different perspective," she said. "A lot of times, surgery patients are having elective procedures. They're people who need care for a few days and then they're gone. But it's a process with aphasia patients. You see them getting their lives back."
Joe Darrah is an ADVANCE contributing editor.
Types of Aphasia
The most severe form of aphasia involves patients who can produce few recognizable words and understand little or no spoken language. Patients can't read or write. Global aphasia is often seen immediately after a patient has sustained a stroke and may rapidly improve if damage is not extensive. However, with more significant brain damage, severe and lasting disability may result.
In this form, speech output is severely reduced and limited mainly to short utterances of fewer than four words. Vocabulary access is limited and formation of sounds is often laborious and clumsy. A person may understand speech relatively well and be able to read, but be limited in writing. Broca's aphasia is often referred to as "nonfluent aphasia" because of the halting and effortful speech associated with this disorder.
Patients exhibit a persistent inability to supply the words for things they want to talk about, particularly significant nouns and verbs. While fluent in grammatical form, speech output is full of vague circumlocutions and expressions of frustration. People with anomic aphasia understand speech well and, in most cases, read adequately. Difficulty finding words is as evident in writing as in speech.
Patients' ability to grasp the meaning of spoken words is chiefly impaired, while the ease of producing connected speech is not much affected. Wernicke's aphasia is often referred to as "fluent aphasia." However, speech is far from normal: sentences do not hang together and irrelevant words intrude, sometimes to the point of jargon. Reading and writingare often severely impaired.
Mixed, nonfluent aphasia
Diagnosed in patients who have limited speech abilities, this form often resembles severe Broca's aphasia. However, patients with this form remain limited in comprehension of speech and cannot read or write beyond an elementary level.
Other varieties of aphasia
There are many other possible combinations of deficits that do not exactly fit into these forms. Some components of complex aphasia syndrome may also occur in isolation. This may be the case for disorders of reading (alexia) or disorders affecting both reading and writing (alexia and agraphia) following a stroke. Severe impairments of calculation often accompany aphasia, yet in some instances patients retain excellent calculation in spite of the loss of language.