Toolkit

Stroke Awareness

Communication and Swallowing Difficulties Following a Stroke

Speech-Language Pathologists Can Help

More than two-thirds of people who have had a stroke experience communication and/or swallowing difficulties. Communication and swallowing difficulties often occur together, are usually most severe immediately after the stroke and often improve over time. Recovery can continue for many years and is most successful when rehabilitation is started as soon as possible after the stroke.

Communication difficulties experienced following stroke vary depending on the part of the brain affected by the stroke. Some people cannot speak at all, some know what they want to say but are unable to find the right words or pronounce the words properly, some have difficulty understanding the words they hear, and others may not be able to read and write. Communication difficulties can be very frustrating and frightening for the person who has had a stroke and his or her caregivers.  Communication difficulties often affect the ability to have conversations and can be very isolating.

Swallowing Problems (dysphagia) often include problems such as choking, inhaling food or drink, or malnutrition and dehydration. People with swallowing problems are more likely to get pneumonia, which can be a serious medical complication and further affect stroke recovery. People with swallowing problems may feel excluded from social activities involving eating and drinking and can suffer from anxiety and depression.

Speech-language pathologists are experts in communication and swallowing difficulties and are core members of the stroke rehabilitation team. Speech-language pathologists assess communication and swallowing abilities and provide individualized therapy and strategies to help people who have had a stroke, their family members and caregivers.

Communication Difficulties Following Stroke

Communication difficulties that occur frequently after stroke are:
  • Aphasia
  • Dysarthria
  • Apraxia of Speech
  • Cognitive-Communication Disorders
  • Hearing Loss

Aphasia

Aphasia results when a stroke damages the area of the brain that controls language (on the left side of the brain in most people). Aphasia occurs in about 30% of people who have had a stroke. Aphasia can range from mild to severe depending on the size and location of the stroke. People with aphasia may have difficulties speaking, listening, reading and writing. Aphasia makes a person look less competent than they actually are. People with aphasia know more than they can say and can usually make decisions and direct their care when they have communication supports.

Speech-language pathologists assess for aphasia and provide speech and language therapy that is tailored to the person’s specific needs. Speech-language therapy is recommended for people with aphasia and is offered individually or in groups. A number of organizations also run community aphasia groups which use supported conversation techniques and give people with aphasia the opportunity to communicate in a social environment.

A speech-language pathologist can indicate if the person with aphasia would benefit from computer-based therapy and/or a communication device.  A speech-language pathologist can train family, friends and caregivers to become more effective conversation partners for the person with aphasia. This training has great benefits for improving communication between conversation partners and the person with aphasia.

Tips for Caregivers

  • Reduce or eliminate background noise when communicating.
  • Get the person’s attention before you start speaking.
  • Keep your language simple, but appropriate for an adult.
  • Speak slowly and clearly using your normal voice.
  • Give the person with aphasia time to speak. Don’t interrupt.
  • Keep a pen and paper handy.
  • Encourage drawing or gestures to help with communication.
  • Print the main key words of your message to help with comprehension.
  • Ask questions that need a yes or no answer.

To help raise public awareness about aphasia and the importance of speech-language pathology services in assisting individuals with aphasia, Speech-Language & Audiology (SAC) has partnered with the Aphasia Centre of Ottawa to profile four clients of the Centre. 

Aphasia is a communication disorder that results when one or more areas of the brain that control language are damaged. It does not impair intelligence. The most common cause of aphasia is stroke however, some people have a progressive disorder called primary progressive aphasia (PPA). People with aphasia may have difficulties talking, listening, reading and writing.

Over 100,000 Canadians live with aphasia, yet the disorder is not widely known. Speech-language pathologists and communication health assistants work with people with aphasia to develop strategies to help them communicate. This support may be provided through individual and/or group sessions.

To help raise public awareness about aphasia and the importance of speech-language pathology services in assisting individuals with aphasia, Speech-Language & Audiology (SAC) has partnered with the Aphasia Centre of Ottawa to profile four clients of the Centre. 

Speech-Language & Audiology Canada would like to thank the Aphasia Centre of Ottawa for the opportunity to speak with some of their clients about their experience living with aphasia.

Christina was diagnosed with aphasia following a stroke 10 years ago. Like many people, Christina had not heard of aphasia before her stroke suddenly left her unable to speak.

Originally from Germany, she lived all over the world before settling in Canada. A mother and grandmother Christina was a healthy active person prior to her stroke and enjoyed working as a tour guide. “Then suddenly there was the stroke and everything was gone.” Unable to speak following her stroke Christina moved to Ottawa to be closer to her son and chose to live on her own to maintain her independence. An important value to her, working with the Aphasia Centre of Ottawa has helped Christina to continue living independently in her own home.

When asked how aphasia has impacted her life Christina tries to focus on the positive but admits it is not always easy:

Christina is grateful she is still able to read.  While she often struggles to find words and has difficulty speaking she is still able to find joy in reading. She also engages in hobbies such as playing the auto harp.

As a person who values her independence, Christina is grateful for the support she has received from the Aphasia Centre of Ottawa:

Christina encourages those living with aphasia to not give up and keep trying.

Joan was diagnosed with aphasia following a stroke 3 years ago. The mother of two adult children had just returned home from a church event when her husband noticed a change in her speech and took her to hospital. Prior to her stroke Joan liked to be out doing activities, whether shopping for gifts for her godchildren or volunteering with her church. Now she describes herself as a homebody who focuses on solitary hobbies like painting. 

When asked about the impact of aphasia on her life, Joan describes how she feels when she is struggling to find the right words:

Joan enjoys using her tablet, “it helps me to learn again how to do different kinds of things, for example, at one point I couldn’t do the ABC’s.” Joan also finds the ability to read helpful in finding different ways to overcome the communication gaps caused by aphasia. 

Her group program through the Aphasia Centre of Ottawa has also played an important role in Joan adjusting to life with aphasia. She finds it helpful to work on her speech with other people who understand the challenges she is facing.

Joan says the number one thing she would tell people about aphasia is that even though you don’t have control sometimes you don’t have to give up. “When something happens in your life you have to move on and try to figure out how you can work with the situation.”

Mark began noticing symptoms of aphasia about 4 years ago. He has lost his ability to read and write and has recently started working with the Aphasia Centre of Ottawa. 

A historian by profession, aphasia has had a profound impact on Mark’s day to day life and he worries about whether he will experience more changes in his ability to communicate in the future.

The father of two has tried to seek out alternative forms of interest such as drawings which he calls “doodles” that he uses to help him express himself. He has also found podcasts helpful in filling the void left by the loss of his ability to read independently. “I can listen to many of the same things that previously I would have done silently.”

Mark has just started working with the Aphasia Centre of Ottawa and is hopeful the staff at the Centre can provide some guidance and assist him to live with aphasia. 

While he is very much aware of how much he has lost because of aphasia, Mark wants people to know that there are also important and interesting things he has come to enjoy through his experience living with aphasia.

Mark tries to focus on what he can do in the moment and plan for the days to come. “There are days when I have to admit that I feel like I am just falling apart, but there are other days where I feel quite at home.” 

Roberta lives with primary progressive aphasia which she says affects her ability to remember words. Originally from New York, Roberta worked as a high school art teacher in the US and Canada. She describes her experience with primary progressive aphasia as a gradual progression from struggling to recall nouns to more general communication difficulties.  

Living with aphasia has been an adjustment for Roberta and her husband but she tries to find humour where she can.

Roberta has found that the group therapy provided by the Aphasia Centre of Ottawa has helped her to adjust to her diagnosis. She finds happiness in the Centre community and appreciates the opportunity to talk with other group members about their interests and experiences living with aphasia. She thinks many people with aphasia would feel sad if they could not attend group therapy, describing it as “the thing we can do.” 

She highlights the importance of being able to communicate:

She describes the frustration people with aphasia can feel when trying to communicate in the “real world”.  Roberta’s strategy for overcoming communication gaps is to tell a person she has aphasia and give them a small card from the Aphasia Centre of Ottawa with communication tips such as speaking slowly in short sentences. She acknowledges that some people may be afraid to say they have aphasia, but her advice is that not saying anything can sometimes make things worse. “I find it good to actually just say something.”

Dysarthria

Dysarthria is a speech problem often resulting from weak or paralyzed speech muscles (face, tongue and throat). Dysarthria is present in about 40% of stroke survivors. The speech of a person with dysarthria may be described as slurred, mumbled or slow.

Speech-language pathologists test for dysarthria by looking at the movement of the speech muscles and assessing voice quality and breath support for speech. Speech therapy may include exercises for the speech muscles as well as speaking activities. Sometimes the speech-language pathologist will recommend a communication device.

Tips for Caregivers

  • Reduce distractions and background noise when communicating.
  • Watch the person carefully as he or she talks.
  • Ask the person to repeat just the part of his/her message that you don’t understand.
  • Ask the person to write his or her message.
  • Ask questions that require a yes or no answer.

Apraxia of Speech

Apraxia of speech is an inability to move the lip and tongue muscles into the right place for speech, even though the speech muscles themselves are strong. About 10% of people have apraxia of speech after stroke, almost always with aphasia. Often people with apraxia of speech struggle to form the correct mouth position needed to make sounds, and have difficulty moving from one sound to another or from one word to the next. People with oral apraxia may have problems coordinating the muscle movements needed for chewing and swallowing.

Speech-language pathologists test for apraxia of speech by looking at the movement of the tongue and lips and by listening to speech sound production. Speech-language pathologists work with people with apraxia of speech to improve their speech. Sometimes the speech-language pathologist will recommend a communication device.

Tips for Caregivers

  • Encourage the person to speak slowly.
  • Allow the person plenty of time to speak. Do not interrupt.
  • Ask the person to write his or her message, or use gestures.

Cognitive-Communication Disorders

Some strokes can affect memory and thinking processes like attention, concentration and problem solving. These difficulties can affect a person’s ability to communicate well. These difficulties may not be obvious, but can affect a person’s ability to return to work and function independently. Some people with a stroke on the right side of the brain have difficulty understanding jokes and metaphors, making inferences, understanding facial expressions and body language, and knowing when to take a turn in conversation. They may not be aware that they are experiencing any problems.

Speech-language pathologists test communication skills and also the memory and thinking skills that are important for communication. Working with a speech-language pathologist, a person with cognitive-communication disorders can develop coping strategies useful for his or her everyday life.

Tips for Caregivers

  • Reduce distractions like TV and radio when communicating.
  • Be sure to have the person’s attention before you start speaking.
  • Use direct language, and avoid sarcasm, metaphors and other abstract language.
  • Use calendars, notepads, smart phone/tablets to remind the person of important information.
  • Break down information or instructions into small parts and repeat as often as necessary.

Hearing Loss

Although a sudden onset of hearing loss is not common following a stroke, many stroke survivors have difficulty hearing. Hearing problems can affect the ability to communicate. Hearing aids or other amplification devices can often help.

Portrait photo of an older person

Tips for Caregivers

  • Arrange for a hearing test by an audiologist if you suspect hearing loss (your family doctor can refer you or you may contact an audiologist directly).
  • Remind the person to wear his or her hearing aids if he or she has them and ensure the hearing aids (and the person’s hearing) have been tested within the last year.
  • Reduce background noise like TV and radio when communicating.
  • Speak clearly, but do not shout.
  • Ensure the person can see your face when you are speaking.

Swallowing Difficulties Following Stroke

Dysphagia is the medical term for difficulty swallowing. Following stroke, dysphagia can be caused by problems using the muscles of the mouth and throat to move food from the mouth towards the stomach. Approximately 55% of people who have a stroke have swallowing difficulties during the first days and weeks. Many people regain their swallowing ability within the first month after the stroke. However, as many as 35% of people still have some swallowing difficulties three months after the stroke. Signs of dysphagia include: difficulty moving food around the mouth or clearing food from the mouth; coughing, choking, or throat clearing when eating or drinking; “gurgly”/wet sounding voice during or after eating or drinking; complaints of food getting stuck in the throat; repeated bouts of pneumonia; or unexplained weight loss.

Because dysphagia may lead to serious medical complications, every person who has had a stroke should have a swallowing screening test once alert and able to take food/liquid by mouth. If the person fails the screening test, a speech-language pathologist will do a full swallow assessment. After completing the assessment, the speech-language pathologist may recommend helpful strategies and procedures to treat or manage the swallowing problem.

Tips for Caregivers

  • Allow the person with dysphagia to feed himself/herself whenever possible.
  • Encourage small mouthfuls (teaspoon size).
  • Ensure that the person is sitting upright whenever eating or drinking.
  • Encourage the person to eat and drink slowly, and allow time for swallowing between mouthfuls.
  • Remind the person with dysphagia not to talk while chewing or swallowing.
  • Ensure the person with dysphagia eats or drinks only when fully awake and alert.

Finding Help for Communication and Swallowing Difficulties

Anyone who has communication and/or swallowing difficulties after a stroke can benefit from speech-language pathology services. In hospital, a referral to a speech-language pathologist can be arranged by the health care team. If the person who has had a stroke is at home, find a speech-language pathologist by:

  • Speaking with your family doctor.

  • Contacting the Speech-Language Pathology Department of your local hospital, rehabilitation centre, or community health service to find out what services are available in your area.

Acknowledgments

Ellen Cotton, S-LP (C)

Sherry Darling, S-LP (C)

Vivienne Epstein,  S-LP (C)

Dr. Rosemary Martino, S-LP (C)

Dr. Elizabeth Rochon, S-LP (C)

Susan Watt, S-LP

References

Breitenstein, C., Grewe, T., Flöel, A., Ziegler, W., Springer, L., Martus, P., … & Abel, S. (2017). Intensive speech and language therapy in patients with chronic aphasia after stroke: a randomised, open-label, blinded-endpoint, controlled trial in a health-care setting. The Lancet, 389(10078), 1528-1538.

Dickey, L., Kagan, A., Lindsay, M. P., Fang, J., Rowland, A., & Black, S. (2010). Incidence and profile of inpatient stroke-induced aphasia in Ontario, Canada. Archives of Physical Medicine and Rehabilitation, 91(2), 196-202.

Flowers, H. L., Silver, F. L., Fang, J., Rochon, E., & Martino, R. (2013). The incidence, co-occurrence, and predictors of dysphagia, dysarthria, and aphasia after first-ever acute ischemic stroke. Journal of Communication Disorders, 46(3), 238-248.

Lindsay, M. P, Gubitz, G., Bayley, M., Smith, E. E., on behalf of the Canadian Stroke Best Practices and Advisory Committee (2016). Canadian Stroke Best Practice Recommendations. Ottawa, ON, Heart and Stroke Foundation. Available at www.strokebestpractices.ca (accessed March 2017).

Martino, R., Beaton, D., & Diamant, N. E. (2010). Perceptions of psychological issues related to dysphagia differ in acute and chronic patients. Dysphagia, 25(1), 26-34.

Martino, R., Foley, N., Bhogal, S., Diamant, N., Speechley, M., & Teasell, R. (2005). Dysphagia after stroke: incidence, diagnosis, and pulmonary complications. Stroke, 36(12), 2756-2763.

O’Halloran, R., Worrall, L. E., & Hickson, L. (2009). The number of patients with communication related impairments in acute hospital stroke units. International Journal of Speech-Language Pathology, 11(6), 438-449.

Winstein, C. J., Stein, J., Arena, R., Bates, B., Cherney, L. R., Cramer, S. C., … & Lang, C. E. (2016). Guidelines for adult stroke rehabilitation and recovery: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 47(6), e98-e169.