Speech problems

Definition

Speech problems in seniors may refer either to oral communication itself or to the use of language in general (spoken or written). Language problems (using correct spelling and grammar) and speaking difficulties (using the voice effectively) may both be caused by a range of disorders affecting the brain, cranial nerves, muscles, or the structures of the mouth and throat. Speech problems in seniors are serious because they can interfere with the senior's ability to get help when needed as well as lead to social isolation and psychological depression .

Description

Human speech is a complex activity that requires the coordination of various areas of the brain, the cranial nerves, the respiratory system, the vocal cords, and several sets of muscles in the face, tongue, jaw, and throat. There are two major types of speech problems in seniors, aphasia and dysarthria. Aphasia, which is the more common type of speech-related disorder in seniors, is an impairment of one's ability to express oneself in language or to understand language. It results from brain damage. Dysarthria is impairment of one's ability to articulate (form) word sounds due to the weakness of the muscles involved in speaking or to problems with the nerves that supply those muscles. It is possible for a senior to have both types of speech problems. Both aphasia and dysarthria should be regarded as conditions associated with various neurological or muscular disorders; they are not diseases in their own right.

Aphasia

Aphasia is caused by damage to the parts of the brain that control language. It may cause difficulties with speaking, listening, reading, or writing. Seniors who have trouble using words and sentences are said to have expressive aphasia, while those who have difficulty understanding language are said to have receptive aphasia. Those who have problems with both using language and understanding it are said to have global aphasia. Aphasia may be mild or severe, depending on the extent of brain damage.

Dysarthria

Dysarthria refers to speech problems caused by difficulties in articulating sounds. It may result from weakness or paralysis of the muscles in the respiratory tract, throat, mouth, or jaw caused by stroke or by such disorders as Parkinson's, Lou Gehrig's, Huntington's, or Alzheimer's disease. The type and severity of dysarthria depend on the area of the nervous system that is affected and the muscles it controls.

Demographics

Speech and language difficulties are more common in seniors than in younger adults. Between 3 and 4 percent of adults over 65 have a speech or language disorder. Between 20 and 40 percent of stroke patients develop aphasia; it is estimated that about 80,000 new cases of aphasia in the United States each year are due to stroke. There are an estimated 1 million adults in the United States with aphasia as of the early 2000s.

About 89 percent of patients diagnosed with Parkinson's disease eventually develop dysarthria.

Speech problems affect men and women equally, as far as is known. It is thought that aphasia may be more common among African Americans than Caucasians because African Americans have a higher risk of stroke.

Causes and symptoms

In addition to specific diseases and disorders, the aging process affects seniors' ability to speak clearly. As people get older, their vocal cords become thinner and less flexible and their throat muscles lose some of their tone. As a result, the voice typically becomes lower in pitch and softer in volume. The senior may have mild difficulty articulating sounds, and speak more slowly, with fewer syllables per breath. These changes due to aging do not, however, affect the senior's ability to understand language.

Aphasia

Aphasia in seniors is caused most often by nonprogressive brain disorders (stroke, head trauma, or encephalitis) but can occasionally be caused by a progressive disorder such as a brain tumor. Aphasia can be classified by the part of the brain that is damaged as well as by severity. In Broca's aphasia, an area in the frontal lobe of the brain known as Broca's area is damaged. Persons with this type of aphasia have difficulty expressing themselves; they may use short but understandable phrases or sentences produced with great effort, such as “go bathroom” instead of “I want to use the bathroom” or “Please help me get to the bathroom.” Broca's aphasia is called a nonfluent aphasia because seniors with this type of aphasia cannot form long or complicated sentences. Seniors with Broca's aphasia can usually understand the speech of others to varying degrees and are aware of their own problems with expressing themselves. They may also have weakness or paralysis on the right side of the body because the left side of the brain controls movement on the right side of the body.

Another type of aphasia, called Wernicke's aphasia, results from damage to an area in the temporal lobe of the brain known as Wernicke's area. Seniors with this type of aphasia may speak fluently (speak in long sentences), but what they say may not make sense; they may make up words, substitute one word for another, repeat words, or add unnecessary words to what they say. For example, a person may say, “I was in the rain when the television rang and went to the floor but there was no there there.” Wernicke's aphasia is sometimes called jargon aphasia for this reason; it is sometimes mistaken for the language disorders associated with schizophrenia. Seniors with Wernicke's aphasia often have difficulty understanding the speech of others and are often unaware of their mistakes in speech. They do not usually have problems with weakness or paralysis, however, because Wernicke's area is not close to the parts of the brain that control body movement.

Mild aphasia is characterized by difficulty using long or complex sentences and by occasional problems with finding the right word for something, a condition called anomia. For example, a person with anomia may say “the thing you tell time with” instead of “clock” or “watch.” A person with only mild aphasia, however, can often carry on a normal conversation in many settings. In severe aphasia, the person may say little or nothing, or may be limited to a few words such as “hi” or “thanks.”

Symptoms of expressive aphasia include:

• Speaking only in single words.
• Telegraphic speech. The senior omits such words as “the,” “of,” and “and,” so that their sentences sound like a telegram.
• Words coming out in the wrong order.
• Making up words or using words that make no sense when strung together.

Symptoms of receptive aphasia include:

• Taking a lot of time to understand spoken messages.
• Finding it hard to follow television news reporters or other rapid speakers.
• Misinterpreting figurative speech; taking such metaphors as “sitting pretty” or “growing by leaps and bounds” literally.
• Getting frustrated and depressed when others fail to understand him or her.

Dysarthria

Dysarthria may be caused by disorders that affect the brain directly (Alzheimer's or Parkinson's disease, stroke, cerebral palsy), those that affect motor neurons (amyotrophic lateral sclerosis or Lou Gehrig's disease), or those that affect the muscles of the neck, throat, and chest. Any of these disorders interferes with the senior's ability to form words and sounds in a way that others can understand. Some specific symptoms of dysarthria are:

• Slurred speech.
• Inability to speak above a whisper.
• Slow rate of speech.
• Unusually rapid speech with a mumbling quality.
• Limited ability to move the lips, jaw, or tongue.
• Abnormal speech rhythm; the speech may sound staccato, jerky, or speed up toward the end of a sentence.
• Changes in vocal quality, such as a hoarse, nasal, or stuffy quality to the voice.
• Breathiness; difficulty forming certain consonant sounds such as “R,”, “B,” “F,” or “M.”.
• Drooling.
• Difficulty in chewing or swallowing as well as speaking.

Diagnosis

The diagnosis of speech problems depends in part on the type of accident or disease that has led to brain damage or weakness of the muscles involved in speech. A senior who has been taken to an emergency room with a head injury , brain infection, or stroke will be evaluated by a neurologist as soon as possible to evaluate speech problems as well as body weakness and other symptoms of brain injury. The neurologist may administer a variety of tests at the patient's bedside, such as asking him or her to name objects or to list as many words as possible beginning with a particular letter of the alphabet. In order to pinpoint the senior's speech problems with more precision, however, a speech-language pathologist (a health professional with special training in evaluating and treating speech problems) or a neuropsychologist is usually consulted. These specialists may administer one or more tests to define the senior's aphasia. Common tests of this type include the Boston Diagnostic Aphasia Examination, the Western Aphasia Battery, the Boston Naming Test, the Token Test, and the Action Naming Test. The National Institutes of Health (NIH) Stroke Scale may also be used to evaluate the patient's speech as well as his or her sensory perception and ability to move the limbs..

In addition to tests of speech problems as such, the neurologist will also usually administer a mental status examination and order imaging studies to look for damage to Broca's or Wernicke's area. These studies may include CT scans , PET scans, MRIs, or functional magnetic resonance imaging (fMRI).

Dysarthria may be more likely to be evaluated initially by the senior's primary care physician. In many cases the fact that the senior has a speech problem is obvious to the doctor because a caregiver has had to accompany the senior in order to describe the situation. A primary care physician can administer a mini-mental status examination as well as evaluate the senior for visual or hearing disorders that may be contributing to the speech problems. The doctor will also check the patient's throat and esophagus to rule out infections of the vocal cords or digestive disorders that may be affecting speech.

Since speech problems may be an early indication of Alzheimer's or Parkinson's disease, the primary care doctor may refer the senior to a neurologist for further evaluation. The senior may also be examined by a speech-language pathologist, who will watch the movement of the patient's facial and throat muscles as the patient tries to talk; note the amount of breath support for speaking; and evaluate the quality, pitch, rhythm, and other characteristics of the patient's voice. These observations may help to identify the location of the muscles involved in the dysarthria as well as its underlying cause.

Treatment

Treatment of speech problems depends on their underlying cause. Patients with Parkinson's disease or Alzheimer's are usually managed with medications even though these diseases cannot be cured. Brain tumors are usually treated with a combination of surgery and radiation therapy. Speech therapy is usually part of rehabilitation for stroke patients and is recommended for patients with aphasia resulting from head injuries as well.

Speech therapy in the most important part of treatment for seniors with speech problems. The therapist may work with the senior one-on-one or with a group of seniors. The purposes of speech therapy are to maintain the senior's present level of speaking ability, to restore that ability when possible, and to help the senior learn to communicate in other ways when necessary. The senior may be evaluated in a speech laboratory in order to guide individualized therapy. There are a variety of communication methods that seniors with speech problems can use, such as alphabet boards, hand gestures or signs, or various electronic or computer-based devices. In addition, speech therapists can work with family members and caregivers of seniors with dysarthria to help them learn strategies for communicating with the senior.

QUESTIONS TO ASK YOUR DOCTOR

• What type of speech problem does my senior friend or family member have?
• What is the prognosis for full or partial recovery of speech?
• How can I help?

Stroke clubs and other support groups are recommended as part of treatment for speech problems because these groups help seniors to practice their new or relearned communication skills. The groups are also useful in helping family members and caregivers adjust to the senior's difficulties and to practice better ways of communicating with the senior.

Nutrition/Dietetic concerns

Patients with dysarthria should be evaluated by a speech-language pathologist to make certain that they do not have swallowing disorders as well as speech problems.

Therapy

Therapy may consist of medications or surgery as required to treat underlying disorders; however, the mainstay of treatment for speech problems in seniors is speech therapy.

Prognosis

The prognosis of speech problems depends on their cause and severity; it is the underlying disorder and not the aphasia or dysarthria by itself that determines prognoses. There is no cure at present for Parkinson's, Lou Gehrig's, Huntington's, or Alzheimer's disease, and dysarthria related to those diseases usually gets worse over time. Patients with certain types of brain tumors may have a life expectancy of only a few months. The prognosis for speech problems caused by any of these disorders is very poor.

Aphasia caused by stroke may have a favorable prognosis, particularly if the stroke was mild. In general, patients with expressive aphasia have a better prognosis than those with receptive aphasia; patients with Broca's aphasia have a much better chance for recovery of speech than those with Wernicke's aphasia.

KEY TERMS

Anomia —Difficulty in naming objects.

Aphasia —The loss or impairment of the ability to use and understand words.

Articulation —The process of forming word sounds by using the tongue, lips, jaw, voice box, and other structures in the mouth and throat.

Broca's area —An area in the frontal lobe of the left hemisphere of the brain that governs language processing, speech production, and comprehension. It is named for Paul Broca (1824–1880), a French physician.

Dysarthria —Difficulty in articulating words due to disorders of the central nervous system. It is sometimes called a motor speech disorder.

Encephalitis —Inflammation of the brain caused by a viral or bacterial infection.

Speech-language pathologist —A health professional who evaluates and treats people with speech, language, or swallowing disorders that affect their ability to communicate.

Wernicke's area —An area in the temporal lobe of the brain (on the left side in most people) that governs language comprehension. It is named for Karl Wernicke (1848–1905), a German neurologist and psychiatrist who first recognized its role in the type of aphasia that now bears his name.

Prevention

There is no known way to prevent all the possible diseases or traumatic accidents that can lead to speech problems. Some diseases that affect the brain and the muscles that control speech are known or thought to be hereditary. People can, however, lower their risk of stroke—the most common single cause of speech problems—by watching their weight, eating nutritious food, quitting smoking , avoiding alcohol and drug abuse, and getting a healthful level of exercise .

Caregiver concerns

The National Institute on Deafness and Other Communication Disorders (NIDCD) makes the following recommendations for caregivers of seniors with speech problems:

• Use short and simple sentences in conversation.
• Talk to the senior as an adult, not as if he or she is a child.
• Include the senior with aphasia in as many activities as possible, and show that his or her opinions are still taken seriously by other family members.
• Turn down the volume of nearby radios or televisions whenever possible so that the senior is not distracted when trying to communicate.
• Encourage all forms of communication, whether speech, drawing, gestures or pointing, or the use of sign boards or other devices.
• Give the senior plenty of time to talk, and avoid correcting his or her mistakes in speech.
• Get the senior involved in activities outside the house, including stroke groups and other support groups for older people with aphasia.

Resources

BOOKS

Beers, Mark H., M. D., and Thomas V. Jones, MD. Merck Manual of Geriatrics, 3rd ed., Chapter 45, “Speech and Language Disorders.” Whitehouse Station, NJ: Merck, 2005.

Mace, Nancy L., and Peter V. Rabins. The 36-Hour Day: A Family Guide to Caring for People with Alzheimer Disease, Other Dementias, and Memory Loss in Later Life, 4th ed. Baltimore, MD: Johns Hopkins University Press, 2006. Includes some helpful advice about communicating with seniors who have speech problems.

National Aphasia Association. The Aphasia Handbook: A Guide for Stroke and Brain Injury Survivors and Their Families. New York: National Aphasia Association, 2004.

PERIODICALS

Bakheit, A. M. et al. “The Rate and Extent of Improvement with Therapy from the Different Types of Aphasia in the First Year after Stroke.” Clinical Rehabilitation 21 (October 2007): 941–949.

Marshall, R. C., and H. H. Wright. “Developing a Clinician Friendly Aphasia Test.” American Journal of Speech Language Pathology 16 (November 2007): 295–315.

Medina, J., and S. Weintraub. “Depression in Primary Progressive Aphasia.” Journal of Geriatric Psychiatry and Neurology 20 (September 2007): 153–160.

Ogar, J. M., N. F. Dronkers, S. M. Brambati, et al. “Progressive Nonfluent Aphasia and Its Characteristic Motor Speech Deficits.” Alzheimer Disease and Associated Disorders 21 (October-December 2007): S23–S30.

Santacruz, Karen S., and Daniel Swagerty. “Early Diagnosis of Dementia.” American Family Physician 63 (February 15, 2001): 703–718.

OTHER

American Speech-Language-Hearing Association (ASHA). Aphasia. Available online at http://www.asha.org/public/speech/disorders/Aphasia.htm [cited March 11, 2008].

American Speech-Language-Hearing Association (ASHA). Dysarthria. Available online at http://www.asha.org/public/speech/disorders/dysarthria.htm [cited March 11, 2008].

Kirshner, Howard S. “Aphasia.” eMedicine, February 5, 2008. http://www.emedicine.com/neuro/topic437.htm [cited March 11, 2008].

National Institute on Deafness and Other Communication Disorders (NIDCD). Aphasia. Bethesda, MD: NIDCD, 2002. Available online at http://www.nidcd.nih.gov/health/voice/aphasia.htm [cited March 12, 2008].

National Institutes of Health (NIH). NIH Stroke Scale (NIHSS). Available online at http://strokecenter.stanford.edu/scales/nihss.html [cited March 12, 2008].

ORGANIZATIONS

American Speech-Language-Hearing Association (ASHA), 2200 Research Boulevard, Rockville, MD, 20850, (800) 638-8255, (301) 296-8580, http://www.asha.org/default.htm.

American Stroke Foundation, 5960 Dearborn, Mission, KS, 66202, (913) 649-1776, (866) 549-1776, (913) 649-6661, http://www.americanstroke.org/component/option,com_frontpage/Itemid,1/.

Aphasia Hope Foundation (AHF), P.O. Box 26304, Shawnee Mission, KS, 66225, (913) 839-8083, [email protected], http://www.aphasiahope.org/index.jsp.

National Aphasia Association (NAA), 350 Seventh Avenue, Suite 902, New York, NY, 10001, (800) 922-4622, http://www.aphasia.org/index.html.

National Institute of Neurological Disorders and Stroke (NINDS) Brain Resources and Information Network (BRAIN), P.O. Box 5801, Bethesda, MD, 20824, (800) 352-9424, http://www.ninds.nih.gov.

National Institute on Deafness and Other Communication Disorders (NIDCD), 31 Center Drive, MSC 2320, Bethesda, MD, 20892, (301) 496-7243, (800) 241-1044, (301) 402-0018, [email protected].

Rebecca J. Frey Ph.D.