E-26 Communication
Disordered communication between a patient and a professional is common and is not confined to patients with a neurological disease. The three crucial skills needed are recognising a communication disorder, diagnosing the type of disturbance, and knowing the most effective way to improve the patient’s communication. This is in addition to the vital professional skill needed, the ability to communicate with all patients, including those with conditions affecting communication. Although primary neurological conditions such as motor neurone disease and stroke are well-known as causes of limited communication, disorders such as psychoses, emotional disturbance, functional illnesses, local oropharyngeal disease, deafness, and blindness all alter communication. Given its central role in establishing and maintaining social and interpersonal relationships, competency in managing patients with impaired communication is vital.
Table of Contents
The competency.
The competency is that the expert is able to assess and analyse any communication disorder to discover its nature and cause, and able to suggest most probable methods for the patient to improve communication. This competency covers all types and causes of reduced ability to communicate. A downloadable document gives the behaviours, knowledge, and skills associated with this competency and a list of references leading to the broader literature.
Introduction
All animals interact with each other, but humans do so vastly more than any other species, communicating vastly more information and using highly complex concepts such as justice or health. The extensive use of video-conferencing and video telephony since Covid-19 struck will have convinced most people there is more to communication than sounds and what people look like on a screen. Virtual communication is much more serial rather than parallel and depends much more on words rather than gestures, posture, expressions, etc.
Alterations in communication occur in many disorders. A depressed person speaks slowly with no tonal variation, a person with Parkinson’s disease loses volume and lacks variation, and someone with delirium seems to be living in a different world. Many of these changes are valuable in reaching a diagnosis but do not need specific management; treating the disorder will help some, but others do not cause sufficient difficulties to warrant intervention.
Many patients attending rehabilitation services will have disordered communication sufficient to impact the person’s social interactions and ability to live independently. This competency is centred on this group and on improving communication.
The field of communication disorders is vast, and this page cannot cover all aspects. I will raise some areas of interest that may need to be noticed by people concentrating on the medical aspects, especially dysarthria (slurred speech) and aphasia (impaired language). Thus, in addition to
speech, writing, listening, and reading, one must think about:
- Gestures, mime, imitation, etc, using hands and the whole body
- Facial expressions
- Non-verbal noises
Communication and mental capacity
Healthcare workers must support patients when making decisions, which is particularly important when someone’s communication is impaired. Two of the four questions recommended concern communication: understanding the information provided and communicating their decision. Thus, the assessor must investigate linguistic barriers to understanding information and ease them as far as possible. They must consider the reliability of the given answer, whether it conveys what the person wishes to say accurately.
Mark Jeyes and his colleagues studied mental capacity assessments in hospitals and intermediate care settings, finding that patients may not have received the communication support they needed. In a later qualitative study in care homes, they found staff recognised communication difficulties, including not knowing English, and offered some support. Nonetheless, they found assessment challenging and would appreciate a supporting toolkit.
In a paper entitled, “Giving voice to people with communication disabilities during mental capacity assessments, ” they described the development of a tool, the Mental Capacity Assessment Support Tool (MCAST), which includes a helpful Communication Screening Tool, available as supplementary material. An evaluation of this tool found the MCAST was acceptable and easy to use and significantly improved the quality of the assessment and the confidence of staff.
Communication: slurred speech (dysarthria).
An international expert on communication disorders, dysarthria, and rehabilitation, Pam Enderby has divided slurred speech (dysarthria) into six types.:
- flaccid dysarthria associated with lower motor neuron weakness of articulatory muscles
- spastic dysarthria related to upper motor neuron lesions in tracts from the motor areas of the cerebral cortex,
- ataxic dysarthria, related to disorders of cerebellar function,
- hyperkinetic dysarthria, arising in extrapyramidal motor disorders
- hypokinetic dysarthria, also related to extrapyramidal motor disorders
- a mixed dysarthria associated with central nervous system damage in more than one area,
Rita Chiaramonte and her colleagues have reviewed all studies (up to 2019) concerned with dysarthria associated with stroke. Their paper gives valuable insight into the many different interventions used; there are many. They conclude that the evidence supporting any intervention is too limited to use. A Cochrane systematic review found the same.
People with severe dysarthria but sufficiently preserved cognitive function may benefit from Augmentative and Alternative Communication (AAC); people with other speech production disorders, such as aphonia, may also benefit. The UK has a national service contract; the 25-page description can be downloaded.
Janice Murray and her colleagues used qualitative methods to study decision-making when considering children. They identified one global theme: competing considerations. The many considerations concerned:
- The patient (the child)
- The family and others to be communicated with (e.g. teachers)
- Access (i.e. usability)
Their finding suggested “that specialised AAC professionals in the UK prioritize access features over language considerations in their communication aid recommendations.”
Language impairment (aphasia)
Language is localised in most people’s dominant hemisphere, typically the left cerebral hemisphere, and usually arises from damage to the left temporal or frontal lobes. Usually, significant language loss occurs after extensive local damage, such as arises from cerebral infarction (stroke). The loss is typically termed aphasia; the word dysphasia is also used. Less extensive damage, such as seen after traumatic brain injury, is not often associated with significant aphasia, though higher-level language skills may be affected. Huykien Le and Mickey Lui have written an up-to-date, helpful summary covering all aspects of aphasia.
Aphasia is strongly associated with stroke damage to the left hemisphere, and about 50% of patients with right-sided weakness will have aphasia. However, one must recognise that the exact localisation of different aspects of language varies; in a study of 17 people with severe global aphasia, there was no single common area of brain damage, and only six of the 17 had damage to the area predicted from population studies.
The Frenchay Aphasia Screening Test can be used to detect aphasia quickly. It is available commercially. It was first published by Professor Pam Enderby and colleagues in 1986. {Note: I have no commercial interest.]
Marion Brady and colleagues identified 57 trials involving 3003 patients investigating speech and language therapy. Their Cochrane systematic review concluded there was evidence to support speech and language therapy’s effectiveness and that the intensity of practice was probably significant in determining benefit.
Cognitive Communication Disorder.
The term cognitive communication disorder first appeared between 1980 and 1990 as people realised that aphasia was not the only type of mental central nervous disorder impairing communication. The unusual communication exhibited by people with a right hemisphere stroke was recognised. At about the same time, patients began to survive quite severe traumatic brain injuries and their disordered communication was recognised. Many measures of cognitive-communication disorders can be found.
Crystal Kelly and her colleagues used a qualitative methodology to study “The pervasive and unyielding impacts of cognitive-communication changes following traumatic brain injury.” The main themes they identified were difficulties arising from:
- Self-awareness of communication changes – patients were generally unaware of changes
- Fatigue – communication was affected by the early onset of fatigue
- Self-identity and life roles –impaired communication causes embarrassment, and the person no longer fits into social groups.
These features are what might be expected after traumatic brain injury.
People with a cognitive communication disorder associated with right hemisphere stroke damage have a different pattern of loss. Eric Rodriguez and his colleagues compared narrative speech output from 50 people with right hemisphere damage with the production from 75 matched controls doing the same task. The formal lexical and syntactic aspects of communication were generally preserved. However, patients produced more words but less information and were less coherent.
Many other aspects of communication may be altered in people with a right hemisphere stroke. Recently, Jamila Minga and colleagues proposed “Apragmatism: The renewal of a label for communication disorders associated with right hemisphere brain damage.” This term shows that cognitive communication disorders may differ according to the nature and extent of brain damage. They said, “adults with RHD may demonstrate tangential or verbose communication, insensitivity to others’ needs and feelings, prosodic changes, minimal gesture use and facial expression, and more. “
Therefore, it is likely that rehabilitation will need to be tailored to the patient’s deficits and needs, not the label attached.
The broader view.
As with most competencies, the rehabilitation expert must consider how to remediate the specific problem while considering the other losses and factors affecting the person and their longer-term, higher-level outcome. Moreover, one can apply some general principles, such as concentrating on function rather than the affected skill and practising within everyday life rather than in a therapeutic setting.
Ruth Dalemans undertook a qualitative study of people with aphasia to discover their views on social participation. The striking finding (to me, as a research colleague) was how much people with limited communication nevertheless wanted to be engaged and involved and belong to a social group even though their participation was small. The message is clear; however little the person can interact and communicate, ensure they are invited and placed as part of the group. The person wants to be there; the other people should accept them as a group member, for example, by sharing any food or drink, and not worry about their inability to join in.
In other words, to the patient, the value of being there will usually outweigh any frustration or embarrassment arising from an inability to communicate with the group. Excluding someone to avoid the person being embarrassed or frustrated makes them a non-person and is probably more to reduce our distress and discomfort.
Conclusion
People with a communication disorder are at an increased risk of being overlooked, treated as if they were not present and had no wishes or feelings. Rehabilitation experts should thoroughly analyse the situation, provide any available treatments, optimise the environment, ensure access to any equipment needed (especially hearing aids and glasses), and educate family members and carers. Unfortunately, communication limitations often persist. The most crucial aspect of this competency is to remind everyone that the patient remains a person who will want to be present when social activities occur. They may adapt to their loss more quickly than those around them.
