SAC Resource Page: 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

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.

 

  • 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.

 


 

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.

 

  • 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.

 

  • 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.

 

 

  • 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.

 

  • 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.

 

 

  • 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.

    • Using SAC's Find a Speech-Language Pathologist or Audiologist online tool.

     

    A number of community groups and programs assist individuals with aphasia and their families.

    For more information on where to find a speech-language pathologist: 

    Speech-Language & Audiology Canada

    www.sac-oac.ca

     


     

    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.


     

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