Adult acquired speech, language and swallowing disorders

Contents

• Introduction
• Acquired communication and swallowing disorders
• Acquired Brain Injury
  • Dysphasia
  • Cognitive communication difficulties
  • Dysarthria
  • Dyspraxia
  • Swallowing problems and dysphagia
  • Dysphonia
• Progressive neurological disorders
  • Palliative Care
  • Head and Neck Cancer
• Augmentative and Alternative Communication (AAC)
• Dementia
• References

Introduction

Speech and language therapists work across the life span from newborn babies with feeding difficulties, to end of life care. It is estimated that nearly 20% of the population will experience communication difficulties at some point in their lives. Speech and language difficulties are the most common disability in childhood, with 10% of children affected. Between 30 and 40% of stroke survivors have communication or swallowing problems which require speech and language therapy [1]. More information about the work speech and language therapists do can be found by visiting the Royal College of Speech and Language Therapists website.

Acquired communication and swallowing disorders

Speech, language, communication and swallowing disorders in acquired (i.e. not pre-existing) neurological conditions arise as a result of a number of conditions including stroke, traumatic brain injury, progressive neurological conditions (such as Parkinson’s Disease, Multiple Sclerosis, Motor Neurone Disease etc.), and dementia. Adult acquired conditions also include those arising from head and neck cancer and palliative care.
The signs and symptoms vary depending on the cause and site of damage to the brain. The severity is also highly variable.

Acquired Brain Injury

Acquired Brain Injury (ABI) includes:

(a) traumatic brain injury (TBI) which is the term for brain injury as a result of a fall, assault or a road traffic accident;
(b) non-traumatic brain injury which includes damage caused by strokes, tumours, lack of oxygen following surgery or heart attack, infectious diseases such as encephalitis, etc. ABI can affect both adults and children.

The following are speech, language and swallowing impairments which can occur as a result of brain injury or other neurological condition.

Dysphasia

Dysphasia or aphasia is the name for a language disorder that occurs when there is damage to the language centres of the brain. It affects people in different ways but may mean that the person has problems with:

• understanding
• speaking
• reading
• writing

In the most severe cases (global aphasia) the person is unable to understand single words and is unable to communicate by talking, writing, drawing or gesture. People with aphasia are likely to find many everyday activities like talking, reading or watching the TV difficult and frustrating.

Therapy for aphasia may include some of the following:

• Targeting specific difficulties in spoken language, understanding, reading and writing.
• Maximising potential of brain plasticity (the brain’s ability to reorganise itself following input from the environment such as therapy).
• Re-training lost language function.
• Re-learning vocabulary.
• Teaching compensatory strategies, for example changing the environment to support communication.
• Working with others to maximise efficiency of communication.
• Facilitating and supporting lifestyle and identify changes.
• Facilitating access to education, training and employment.
• Exploring the potential to use alternative and augmentative communication systems (e.g. communication aids).

Cognitive communication difficulties

These difficulties are most commonly associated with traumatic brain injury. People with cognitive communication difficulties often cannot:

• Concentration on the conversation.
• Stick to the subject.
• Understand humour, sarcasm and figurative language e.g. “Pull your socks up”.
• Respect personal boundaries/social etiquette.
• Use appropriate topics.
• Provide reasoned arguments.
• Draw appropriate conclusions for information.

This can impact on:

• General conversation skills.
• Understanding what is said.
• Reading books, magazines and emails.
• Expressing thoughts, feelings and ideas.
• Understanding and engaging in humour.
• Understanding bills and official documents.
• Engaging with social media.

The language difficulties after a brain injury can be subtle and although communication seems normal, there may be serious difficulties maintaining relationships or holding down a job.

The following may form part of the therapy for people with communication and swallowing impairment following Acquired Brain Injury:

• Comprehensive assessment of the strengths and weaknesses of communication and or swallowing.
• Establishing a communication/swallowing diagnosis.
• Setting goals to meet the needs of the individual.
• Establishing strategies which can be utilised in everyday life.
• Establishing a rehabilitation programme to work on specific activities.
• Where appropriate working on alternative and augmentative methods of communication (communication aids).
• Working with specific computer programmes to enable practice between sessions (a speech and language therapist is best placed to advise on which programme if any is appropriate).
• Working with the person, their family and friends, to ensure communication is as effective as possible.
• Liaising with employers regarding return to work.

Therapy may take place as an individual or as part of a group.

Speech and language therapists often work as part of multi-disciplinary team with occupational therapists, physiotherapists and neuro-psychologists to ensure all the needs of the person are met in a cohesive way

The recovery pattern is such that therapy may be required across the life span as different challenges are faced. Speech and language therapists’ input is likely to be long-term and important in facilitating a transition e.g. into employment or parenthood. Individuals who may be coping at one point may require intervention as things change.

Dysarthria

Dysarthria is a speech disorder. A person with dysarthria has no difficulties with understanding language or with thinking of the right words to say. The muscles of the mouth, face and respiratory system may become weak as a result of damage to the brain or progressive neurological diseases.

The nature and severity of dysarthria may lead to a number of symptoms including:

• Slurred speech (sounding as if drunk)
• Speaking softly or barely able to whisper
• Slow rate of speech
• Limited tongue, lip, and jaw movement
• Breathiness
• Drooling or poor control of saliva

The person’s speech may be totally incomprehensible as a result of the damage to the brain.

The following may form part of therapy for dysarthria:

• Comprehensive assessment of which aspects of speech are affected (e.g. lips, tongue, voice, breathing).
• Exercises directed at improving breath control.
• Exercises to improve the movement, strength or speed of the muscles.
• Strategies to make speech more intelligible (understandable).
• Working with the person and their family and friends to make communication as effective as possible.

Dyspraxia

Dyspraxia is a motor speech disorder that means it is difficult to sequence the sounds in syllables and words. It may also be called verbal dyspraxia/apraxia. Dyspraxia can also affect other movements in the body, for example difficulty in moving the limbs or difficulties with sequencing tasks such as making a cup of tea or getting dressed. Oral and/or verbal dyspraxia are most often accompanied by some degree of language impairment.

The nature and severity of the dyspraxia may lead to problems with:

• Imitating speech sounds.
• Imitating non-speech movements such as sticking out your tongue.
• Trying to produce sounds (in severe cases this can be an inability to produce sound at all).

Treatment for dyspraxia may involve:

• Comprehensive assessment of language and speech.
• Repeated practice of affected sounds by themselves or in words.
• Practice of important words such as family names.
• Establishing strategies to aid communication if speech has not been effective for example writing, drawing or gesture.

Swallowing problems and dysphagia

The term dysphagia covers not only swallowing problems but also control of all the complex movements needed for eating and drinking. Swallowing difficulties can be a feature of a large number of neurological conditions as well as many others, and can affect both children and adults.

Some of the consequences of un-managed dysphagia include:

• Aspiration pneumonia (a chest infection caused by food and fluid going onto the lungs rather than into the stomach)
• Choking
• Weight loss and/or dehydration because of poor nutrition/fluid intake
• Reduced quality of life
• Family anxiety and distress

Some of the following may occur:

• Signs of distress at meal times and food refusal.
• Coughing and/or choking on food or fluid before, during, or after swallowing.
• Change in facial expression, or eyes watering whilst eating or drinking.
• Change in respiratory pattern e.g. breathlessness, rapid breathing rate.
• Inability to eat all types of food, or slow eating and swallowing.
• Holding food in the mouth and making no attempts to swallow.
• Loss of food from the mouth.
• Feeling of food 'sticking in the throat'.
• Pain on swallowing.
• Inability to manage saliva (drooling, dribbling or coughing on it).
• Inability to manage usual medication such as pills.
• Wet, 'gurgly' voice quality.

Speech and language therapists are often involved with a multi-disciplinary team working with people with swallowing problems including doctors, physiotherapists, occupational therapists, and dieticians.

The following may form part of the therapy input for people with swallowing problems:

• Exercises for the lips, tongue, etc.
• Trials with different food and fluid consistencies.
• Advice on compensatory strategies (e.g. seating position or posture, modifying texture, changing feeding technique).
• Sensory enhancement/stimulation.
• Advice on any onward referral to another department for further investigation (e.g. x-ray).
• Advice regarding whether feeding by mouth is safe or not.
• Re-assessment and review of swallowing function.
• Advice to parents or carers.

Dysphonia

Dysphonia is the term used for disorders of the voice. There are many causes of dysphonia including inflammation of the larynx, lumps (nodules) on the vocal cords, trauma, vocal cord paralysis, psychological (voice changes occurring when people are under stress either at work or at home). Persistent changes (lasting two weeks or more) in the voice should always be checked out with your GP who will refer you on to an ENT consultant. See the voice section for further details.

Progressive neurological disorders

These conditions involve a progressive deterioration in functioning and are likely to affect the individual for life. They include Multiple Sclerosis (MS), Motor Neurone Disease, and Parkinson's disease. Some of the disorders progress more rapidly than others. Some are unpredictable and have periods of relapse and remission such as MS. Communication problems associated with progressive neurological disorders may be similar to those caused by injury or other non-progressive disorders affecting the brain and the body's nervous (neurological) system.

Recognised characteristics of progressive neurological disorders that affect communication:

• Dysarthria (when the muscles needed for speaking and breath control are affected).
• Dysphonia (voice problems).
• Dysphagia (swallowing difficulties).
• Cognitive impairment (at a late stage in some disorders memory and/or thought processes may be affected).
• No speech at all.

Speech and language therapists are often involved with multi-professional teams working with progressive neurological disorders. Speech, voice and language therapy may begin at the initial signs of the disorder and continue on an on-going basis, depending on need and fatigue levels. Management strategies will be given and reviewed as therapy progresses.

Therapy for people with progressive neurological disorders:

• Comprehensive assessment and diagnosis of communication and swallowing disorder.
• Swallowing management advice e.g. food and/or fluid modification, enteral feeding, posture strategies, swallow manoeuvres.
• Speech exercises for lips, tongue, palate, jaw.
• Facial exercises to maintain strength.
• Speech articulation programmes and focus on the rate of speech.
• Voice programmes for breathing, breath control, volume, pitch, syllable stress and vocal tone.
• Assessment and trials of augmentative and alternative communication aids (low– and high-tech AAC).
• Conversation practice.
• Fatigue management for speech production.
• Advice to carers.

Palliative Care

Care for those with life-limiting illness aims to improve quality of life by relief of distressing symptoms. Speech and language therapists may have a part to play advising on dysphagia management. They can also support people in making their wishes known when communication is limited.

Therapists will advise on strategies to achieve the best possible function. They can also offer information to carers.

Head and Neck Cancer

People may experience communication problems arising from:

• Cancer in the mouth, head or neck.
• The effects of surgery, radiotherapy or chemotherapy.

Difficulties will depend on the type of treatment and extent of the disease. Recognised characteristics of Head and Neck Cancer that affect communication include:

• Dysarthria
• Dysphonia
• Dysphagia
• Speech/voice difficulties following laryngectomy (surgical removal of the voice box because of laryngeal cancer)

Speech and language therapists are often involved with multidisciplinary teams working with Head and Neck Cancer pre– and post-operatively, and during rehabilitation. Therapy may begin prior to treatment, depending on the nature of the disease and planned treatment. Management strategies will be given, and will be reviewed at different stages of the treatment process.

The following may form part of speech therapy input for people with Head and Neck Cancer:

• Pre-treatment assessment and counselling.
• Swallowing management advice.
• Exercises for lips, tongue, palate, jaw and face.
• Speech and voice programmes.
• Assessment and trials of augmentative and alternative communication aids (AAC).
• Advice to carers.
• In addition, anyone who has had a laryngectomy will require support from a specialist speech therapist working as part of an ENT multi-disciplinary team.

Augmentative and Alternative Communication (AAC)

All of these speech and language conditions can have such a profound impact on the person’s ability to communicate that speaking or writing is no longer possible or insufficient to get their messages across. In this instance a speech and language therapist may utilise Augmentative or Alternative Communication (AAC). This term covers ways of communicating that add to, or replace, speech and handwriting with signs or symbols; voice output communication aids (VOCAs) and computer-based technology may be used.

People (children or adults) may have difficulty expressing themselves so that they are able to be understood by others. This could be due to lack of speech, difficulties with speech intelligibility, motor speech difficulties (controlling the physical movements necessary for speaking), or difficulties with voice production and breath control.

An AAC user employs a system to enable expressive communication. This could be through:

• signing
• use of symbols
• communication books containing frequently used words, pictures or symbols
• low-tech communication aids (such as a small chart with symbols for essential needs, or a tool with a very limited message content)
• high-tech communication aids (e.g. VOCAs) such as that used by Stephen Hawkins

Therapy should begin as soon as possible to give individuals needing AAC a mode of expressing themselves. For some, AAC may be a continuing need throughout their life and a therapist will be involved in updating systems to match new needs and make use of improved tools, for example, the ever changing and improving world of web applications (apps).

The following may form part of the therapy input for people with AAC needs:

• Assessment of the individual's ability to express themselves in a way others can understand.
• Assessment alongside others (e.g. family, occupational therapist, physiotherapist, as appropriate) to look at availability and suitability of systems.
• Liaison with family and significant others to educate them about the AAC system the individual is using.
• The AAC method will require regular updating as vocabulary increases and needs change.
• And/or regular therapy.

Dementia

Dementia is a term which describes a collection of symptoms which include a decline in memory, reasoning and communication skills. Swallowing problems also occur, most frequently in the latter stages.

There is a broad range of communication difficulties associated with dementia. These change over the course of the illness. They can include:

• Repetition of topic.
• Reduced amount of speech.
• Problems with turn-taking.
• Difficulties with understanding what is said.
• Difficulties with reading, writing and maths.

The following may form part of the therapy for people with dementia:

• Using strategies to support memory.
• Developing communication strategies.
• Advising on strategies to cope with challenging behaviour.
• Providing education and information to the person with dementia, their relatives and carers.
• Supporting the person in decision making and making choices.
   

References

1. Marsh K., Bertranou E., Suominen H., Venkatachalam M. 2010. An economic evaluation of speech and language therapy. Matrix Evidence.

For further information on the author of this article, Speech and Language Therapist, Ms Liz Ackroyd, please click here.