Are they linked? Is it treatable? How can speech therapy help?
Aphasia - a language disorder that makes it difficult to communicate
Dementia causes aphasia in the advanced stages of the disease. It starts gradually but can become severe in the later stages of dementia. Some people become nonverbal or mute.
Aphasia could also occur after a person with dementia suffers a stroke and experiences sudden changes in language abilities. Their response to therapy is less straight forward because of the underlying dementia and should be approached differently.
How Aphasia Shows Up in Dementia
First, lets look at aphasia caused by the progressive nature of dementia. The initial sign of difficulty with language is usually having trouble with word finding (anomia). If good at circumlocution, they might be rather quick at finding a substitute word or describing the word so the conversation may continue without much delay and maybe without the notice of others. If it progresses, aphasia can cause bigger delays and more complications in communicating. Some people have difficulty finishing a thought or answering questions. Some people have difficulty retaining or comprehending lengthy amounts of verbal information. Some people have trouble with initiating communication and need to be prompted to let others know when they need something, like assistance to the bathroom. There is a link between cognition and communication, and it can be difficult to tease apart whether it is the cognitive impairment making it difficult to respond to a question versus a language deficit. A speech language pathologist (SLP) can help identifying and treating each.
Is aphasia in dementia treatable? Yes, but...
Speech language pathologists are experts in analyzing and identifying communication supports and speech therapy can maximize communication in a loved one who has dementia. We find alternative methods of communicating or suggest modifications to reduce or eliminate confusion or distractions that might be impacting communication success. We then collaborate with caregivers and family members in how to optimize what a person with dementia can express and understand.
But because aphasia caused by dementia is progressive, it is constantly shifting. A speech language pathologist might make headway in identifying what level of assistance is needed for communication success in the home or a memory care center. Ideally, the progression of the disease stabilizes and the strategies and aids work for a while. But over time things change and a re-assessment might be needed to update the strategies and to find what works in the next stage of dementia. Consulting speech therapy several times over the course of dementia would not be unusual.
When a Stroke Causes Aphasia in a Person with Dementia
The prevalence of persons with dementia who endure a stroke is not known. One study found an occurrence of 16%. Another study found the prevalence to be 10%. Although both of these numbers are relatively small, when it happens, it is an unwelcome complication to an important quality of life measure—communication.
When a stroke causes aphasia in a person with underlying dementia, it can have detrimental effects on simple interactions and overall functioning. The good news is generally there is the ability to regain lost function after a sudden event, such as a stroke or head bleed. The bad news is, it is harder for the SLP to assess and harder for the stroke patient to recover than if dementia was not in the equation.
Recovery of language after a stroke depends on many factors (check out my blog for more on that). Generally speaking, stroke recovery usually has rapid improvement in the first few days and then next few months of treatment. Underlying dementia adds a complicating factor in that recovering the neuropathways for language are hindered by the degenerative process that has been gradually occurring for years. We cannot expect to see recovery of language beyond where the person was before the stroke, but there could be success in regaining some of the language affected by the stroke, or in modifying communication to still give success.
The Role of the Speech Language Pathologist
After completing a test of receptive and expressive language skills, reading, writing, cognitive skills and maybe object and picture identification, an SLP can then make recommendations on the best method of communicating with the person who has dementia. In some cases, it may take more than one visit. Ongoing speech therapy will help in training the new strategies, not just for the person with aphasia but everyone involved in their care. Speech therapy is always individualized so the course of therapy is going to be specialized and different from one person to the next.
What kinds of strategies can be effective for aphasia in a person with dementia?
It can depend on the degree of aphasia and dementia stage. Here’s a start:
Simplify the language. Rather than “Shall we go for a walk now that you’re done with your breakfast?” say “Let’s go for a walk!”
Avoid open ended questions, such as “What would you like to do next?” Instead give choices. Try “Do you want to call your son or watch some television?”
Reduce the choices to two if the person is getting overwhelmed when given too many choices.
Can you add a visual to support the language comprehension? Hold up the two options as you ask, “Do you want orange juice or milk?” Or motion to the bathroom door to ask if they need to use the bathroom.
Written and picture cues. Sometimes written choices are all someone needs to help prompt the word they are searching for. I find this works best in a new setting, like during a hospitalization or rehab stay. Write choices such as: bathroom, water, medicine, call my family. Then when the nurse walks in to ask what is needed, he/she can prompt the patient by having them go through the written list of common requests. If reading is not a strength, pictures can come in handy. [Be sure to have picture identification tested by an SLP before using. The complexity of an image matters, the number of images used at once matters, and in more advanced dementia, they it may not be helpful.]
Always give extra time to process information. Then if needed, give a repetition of the same simplified info.
Minimize distractions and background noise.
Pay attention to your tone and facial expression when interacting with someone with aphasia and dementia. When our language fails us we trust our instincts. Approach someone with dementia using a calm, soothing voice or a kind but firm voice when you need compliance, and you will have more success than what the words could convey.
The SLP Advocate
If you notice a sudden change in language capabilities after a person with dementia has a stroke, ask for a consult with a Speech Language Pathologist. Be sure to give specific details on what the communication capabilities were immediately before the stroke and how it is different after the stroke, so we know best how to help.
Please don’t assume a decline in language skills is the way it’s going to be from now on. Just because the person has dementia doesn’t mean there can be no improvement in communication. If there's a decline in communication with the progression of dementia, ask your doctor for a referral to speech therapy. If there’s a sudden change in communication skills after a stroke, see if there is potential for rehabilitation. And don’t wait. Time is crucial when rehabilitating a stroke.
Advocate for your loved one with dementia. If speech therapy completed an assessment and did not recommend therapy, ask why. If the reasons are sound, you've likely done your due diligence. If you're not satisfied with the response, ask for at least a month of “trial speech therapy” to see how the person with dementia responds. If they are making gains during that time, they are a good rehab candidate and should qualify for more therapy. Be a partner with the speech pathologist and let them know the improvements you are seeing if they are not immediately obvious during therapy sessions. We love to hear that therapy is making an impact on functional day-to-day communication needs. And this is what the insurance will want to hear if they are going to approve more therapy.
Look online for virtual services for people who experience aphasia. But virtually connecting with someone isn't always effective for someone who has dementia. Check to see if there are other in-person resources in your community. Amplify Speech Therapy offers an Aphasia Conversation Group for people to continue to work on their communication skills while building community with other people who also experience aphasia.