Aphasia occurs in stroke, dementia and head injury. Similar problems with language can occur developmentally – adults with learning disability. I think the main issue from a Speech and Language Therapy point of view is that when somebody has aphasia the language difficulties they have in their second language (English) are recognised, however sometimes the person then speaks in their first language with relatives and it may appear that there are no difficulties. Sometimes this is the case but usually in a significant aphasia both languages are affected to some extent.
It is possible an interpreter may come across this issue first and the person they are working with is not able to communicate as well in their first language as was assumed. People with severe expressive aphasia often have some level of comprehension difficulties too but despite this may appear to understand what is being said.
In these situations interpreters may benefit from being aware of the types of difficulties, feeding back to clinical staff their observations and that Speech and Language Therapist assessment may be able to help assess communication further.
Communication problems after a stroke often result from damage to the parts of the brain responsible for language, but the ability to control the muscles involved in speech may also be affected. The specific problems experienced by any one individual will depend on the extent of the damage and which area of the brain has been affected.
For most people, the area of the brain mainly responsible for aspects of language is located in the left hemisphere (side). This means that damage in this region can affect the ability to speak, understand, read and write.
However, damage to the right side may still make communication difficult because it may limit someone’s ability to control crucial movements, affect memory and make coherent organisation of language difficult.
There are many different ways in which the ability to communicate may be affected but, generally, the problems are related either to speaking, or understanding what other people are saying. Short-term memory lapses and difficulty in concentrating can make communication even more problematic for some.
One of the most difficult and common situations is when someone suddenly cannot speak at all after a stroke or what they say does not make sense to you. This is called aphasia. Aphasia (sometimes called dysphasia) does not damage intelligence, but does affect how someone can use language. Speaking, understanding what is said, reading and writing are all communication skills, and can all be changed by a stroke. It can be frustrating for the stroke person as they may believe that they are speaking normally but that other people cannot understand them. Often this arises because the words that come out are not the ones they want to say, or because their sentences are fractured and missing crucial words. The stroke survivor may be unaware of this. Some people use words with related meanings to the one they want – food instead of drink, for example – while others mix the sounds up in words.
Someone who has problems forming the right words because of muscle weakness in the mouth has dysarthria. Dysarthria may also affect breath control and the ability to make sounds, so that speech may sound flat, slurred, nasal or have a jerky rhythm.
An inability to control and co-ordinate the movements that are needed to talk normally is called dyspraxia. A person with dyspraxia may be unable to speak clearly and, in severe cases, to make deliberate sounds at all. It is different from dysarthria because it is not caused by muscle weakness, and is often seen and treated as part of aphasia. Dyspraxia can affect sequencing and the ability to co-ordinate other actions as well as speech, and so may be dealt with by a number of health care professionals.
Anyone with communication difficulties after a stroke should be referred to a speech and language therapist. This can be done by the medical team if they are in hospital or by the GP if they are at home.
Initially, the therapist will assess the person’s strengths and needs in terms of communication and their speech and language skills. Dealing with the problem may involve other people, including health professionals and family and friends, who may be offered advice on how to help the stroke survivor to communicate.
Different approaches to treatment are needed, depending on whether the person has aphasia or dysarthria, although some people have both after a stroke. The therapist will also use various methods to try to establish the precise nature of the difficulties, for example by using pictures.
The therapist can also assess the appropriateness of specialised equipment, such as electronic aids and software programmes to assist recovery and to help with long-term communication difficulties. The NHS also has a small number of Communication Aid Centres that provide assessments and support for people who may benefit from a communication aid. See our factsheet F14 Speech and language therapy after stroke for more information.
All rehabilitation services are time limited, so people are usually offered a fixed number of sessions with the therapist. Speech therapy can also be arranged privately if the person feels they would benefit from further therapy.
The Stroke Association provides communication support services in some areas, plus information about stroke clubs and other voluntary groups (see page 4). Every person who has a stroke is different, and the amount of recovery someone will make is very difficult to predict. Unfortunately some people will have long-term communication difficulties and may need to find alternative ways of communicating, such as using signs or gestures or a communication chart.
There are a number of ways that family and friends can help someone with their communication, but do ask if your help is needed before giving it.
- Establish communication by finding out whether someone can use yes or no (or a signal such as thumbs up/thumbs down) accurately. If they can do this most of the time, then you can ask questions to which the answer is yes or no, to narrow down what they want to say.
- Don’t rush the conversation. Give the person time to take in what you say and to respond, and don’t interrupt them. It is better to assume someone can hear and understand what you say, even if they are not responding much.
- Adjust your communication to the right level. Speak in a normal tone of voice and try to use sentences that are short and to the point. You may need to speak slightly slower than usual.
For example, instead of saying, “Your wife called and she will be here tomorrow to pick you up and take you home”, say, “Your wife called.” (pause) “She will be here tomorrow.” (pause) “You can go home then.”
- Use visual aids to reinforce your verbal message, such as facial expressions, gestures, writing, drawing, or even a Communication chart.
- Stand or sit where you can be seen and heard clearly – poor lighting or distractions do not help.
Remember that spoken words are not the only way to communicate. Help the person to develop skills in as many ways as possible, perhaps making pictures or using gestures and mime.
- Don’t give up. If you can’t work out or guess what someone is trying to say, suggest you take a break and come back to it later. Don’t forget to!
- Don’t pretend to understand. If you’re having difficulty understanding someone, be honest and tell them: “I’m sorry, I don’t understand – let’s try again.”
- Be positive and encouraging and remind them of any progress they have made.
- Make a record. Write down what works best for you both when communicating because a person with aphasia might forget the different ways available to him/her. Make a list and refer to it when communication breaks down.
- Try writing down key words. Drawings and pictures can also help.
- Remember the person has not become less intelligent, so treat them as an adult. You may need to remind less tactful friends and relatives of this.
- Communication is not about perfect grammar and proper sentences, so don’t feel you must always correct “mistakes”.
- Don’t visit in a large group. It is much easier for someone to concentrate if it is just you and them. Background noise and distractions do not help.
- Keep visits short, or take a break during a visit. Someone with aphasia will get tired easily and will not respond well when they are tired.
- What is right for one person may be wrong for another, and you will need to respect the individual’s inclinations and interests just as you did before the stroke.
- Do not get discouraged if you have a day when communication seems completely impossible. The effort can leave all involved feeling tired and frustrated.
Stopping therapy does not mean that there will be no future progress. Self confidence and skills can be increased by practising speech naturally in different settings over time. Try and identify places where the person can practise and develop, and find interests and pursuits that can be enjoyed socially.
They might consider joining a group set up to support people after stroke (stroke club), a communication (or aphasia) support group (run by The Stroke Association or Speakability, see useful organisations) or a local adult education class (some colleges run courses in communication skills, reading and writing).
It is not unusual for someone with aphasia to be depressed and frustrated, and they may need some form of counselling to try and express their feelings about the changes in their life after stroke.
There are many activities, which can be done at home to build communication skills and boost confidence. Having friends’ and family input can really make a difference, as they know the person best, and may share their interests. The younger ones will enjoy the opportunity to join in some games to help re-establish memory and communication, so enlist as much help as possible.
Sometimes it helps to plan a certain time or times to do communication tasks. These are most successful if they are kept short (less than 30 minutes) and planned around times when the person is rested. If you hit a block, stop for the day or change activities.
The following is a list of ideas for tasks and activities that a friend or family member might initiate with the person affected by aphasia, or which might be practised at a communication or aphasia support group.
- Find and use gestures for common action words (for example, eating, drinking, writing, sleeping, shopping etc).
- Gather a box of common objects. Make actions around them. For example: “point to the one you clean your teeth with”, “pick up the cup”.
- Draw pictures of common objects. Say and write their names. Use simple word-search puzzle books.
- Cut headlines and pictures with captions out of newspapers and tell a story about each one. Make a news scrapbook and include whole articles when you are able to read more easily.
- Make a book of family photos, pictures of friends and places visited, and encourage the person to talk about them.
- Print the names of common objects and rooms at home on cards. Encourage the person to read the cards and locate the item or place.
- Play card games such as Beat Your Neighbour or Pontoon to practise numbers.
- Make a chart of daily chores around the house, perhaps with actual photographs of the person doing them.
- Adapt a favourite, simple recipe using pictures and/or drawings for the ingredients and measurements.
- Use maps of the town you live in, the UK and the world. Put them in a book and refer to the maps when talking about various locations.
- Practise writing activities daily, such as copying letters or words, and pick words at random for the person to write down. Encourage the person to write short letters, cards and thank you notes.
- Keep a large monthly calendar in view for birthdays and anniversaries. Encourage the person to enter all appointments and events or write an item of interest for each day.
- Make a journal and include something to mark each day, written or drawn, and items such as a photo, article, invitation or keepsake.
- Limit the amount of TV they watch and seek out interaction with other people to restore the art of communicating.
The Stroke Association
We provide information and support to people affected by stroke. Call our Helpline to see if we have a communication support service in your area. Our staff and trained volunteers work with people, often in groups, to help improve communication.
Stroke Helpline: 0303 3033 100
Communication card: Credit card size.
States: “I have had a stroke and find it difficult to speak, read or write. Please give me time to communicate”. Also has room for name, address and emergency contact.
Communication chart: An aid to communication consisting of four sides of A4 with the alphabet, numbers, a clock and pictures for common words, for example, ‘hungry’, ‘thirsty’, ‘hot’ and ‘cold’. (Price £1.)
The Stroke Association Northern Ireland
Graham House, Knockbracken Healthcare Park, Saintfield Road, Belfast BT8 8BH
Tel: 028 9050 8020
Provides information and support to people with aphasia. Runs conversation groups with speech and language therapists and a home liaison counsellor.
This is a website built by a team of researchers and a group of people with aphasia. It has information about aphasia and people can register as and look for a penpal.
6–18 Marshalsea Road, Southwark, London SE1 1HL
Tel: 020 7367 0840
Provides practical one-to-one and group therapy, and runs courses in London and Bristol for people with aphasia and their relatives.
The Stroke and Aphasia Handbook by Susie Parr, Carole Pound, Sally Byng and Bridget Long Provides easy to understand information on all aspects of life after a stroke. (£20)
A booklet for relatives of those with aphasia to guide them towards better communication. (£7.50)
1 Royal Street, London SE1 7LL
Helpline: 0808 808 9572
Provides resources for professionals and people affected by aphasia, and runs conversation groups around the country.
ASLTIP: Association for Speech and Language Therapists in Independent Practice
Coleheath Bottom, Speen, Bucks HP27 0SZ
Tel: 01494 488306
Royal College of Speech and Language Therapists
2 White Hart Yard, London SE1 1NX
Tel: 020 7378 1200
The UK training and professional body for speech therapy.