How aphasia hamstrings a person's ability to communicate

Host Amber Smith: Upstate Medical University in Syracuse, New York, invites you to be The Informed Patient with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith. More than 2 million Americans are affected by aphasia, but many of us had no idea what it was until news that the actor Bruce Willis had the condition. Aphasia can affect speech as well as how a person writes and understands both spoken and written language.

Today, I'm talking about aphasia with speech-language pathologist Lauren Westby from Upstate's department of physical medicine and rehabilitation. Welcome back to "The Informed Patient," Ms. Westby.

Lauren Westby: Thank you.

Host Amber Smith: How do you describe aphasia?

Lauren Westby: Aphasia is actually caused by damage to the language centers.

Well, our brain is composed of two hemispheres, and language centers are on the left side of the brain. So the damage to the language centers on the left side of the brain can cause aphasia. Aphasia typically occurs after a stroke or a head injury, but it can also come on very gradually from a slow-growing tumor or maybe a neurological condition. It affects your ability to communicate. It can affect your ability to express information, say the words you want to say. But language is multifaceted, and it can affect the other components of language as well, including understanding and reading and writing.

Host Amber Smith: Is it a disease on its own -- aphasia -- or is it a symptom of a disease?

Lauren Westby: It's a symptom of a disease. It can be caused by a stroke or head injury, or again, from the slow-growing tumor or neurological condition, but it doesn't really exist on its own.

Host Amber Smith: Would someone with aphasia recognize that they have it or that something's not right?

Lauren Westby: They might recognize it. It depends on the type of aphasia that they have. It's very dependent on the location of the injury, so somebody with more of a fluent aphasia, like a Wernicke's aphasia, where they have trouble being able to understand language, they may actually have more trouble recognizing where their errors are, as opposed to somebody who has more of a nonfluent aphasia, like a Broca's aphasia, which is where they may understand a little bit better but have more trouble with their output. And then they may recognize their errors more readily.

Host Amber Smith: So it sounds like the symptoms might be different for anyone depending on exactly where this is, but it's the left side of the brain?

Lauren Westby: The left side, yes. And there's actually different types of aphasias. So, as I was saying just a second ago, there's a nonfluent aphasia, which is called Broca's aphasia. And those people may have a better ability to understand than they are able to speak, and they have more trouble getting words out. They may speak in short sentences or omit words, and these are the patients that may have more ability to recognize their errors, as opposed to the fluent aphasia, where they speak much more easily and fluently, but what they're coming out with doesn't make as much sense. The, receptive language is much more impaired in this group. And then our global aphasias are our patients who have the most severe aphasia, in which all the modalities of language are affected.

Host Amber Smith: Is there necessarily cognitive damage if someone has an aphasia?

Lauren Westby: So not necessarily; intelligence has not changed. However, depending on the nature of the injury, cognition can be impacted. So if it's more of a degenerative disease, so more of a progressive primary aphasia that correlates with the dementia or a traumatic brain injury, we might see some additional cognitive deficits in conjunction with the language impairments.

Host Amber Smith: Well, with dementia and stroke affecting usually older people, you probably see this in older people, or do you ever see aphasia in younger (people)?

Lauren Westby: Yeah, we can see aphasia in younger people. It does typically impact an older population than younger, but I think across the ages, we can see aphasia.

Host Amber Smith: Does aphasia run in families or is it genetic? If your father had it, are you more likely to get it?

Lauren Westby: No. Most aphasias are caused by the circumstances, and they're not inherited, although there is some research that primary progressive aphasia has been linked to inherited factors. So about 40% to 50% of people with a primary progressive aphasia have other family members who are also affected by the disease.

Host Amber Smith: Well, let's talk about treatment. Can the damage be reversed?

Lauren Westby: In terms of stroke and brain recovery, the typical timeframe for recovery is about six months to a year. And that recovery is going to depend on a number of conditions, including the cause and extent of the damage in the brain, but the brain is also changing and learning. And so you can see a recovery for much longer than that, but your speech-language pathologist is going to be the person that will do your assessment and develop an individualized treatment plan.

Host Amber Smith: What does speech therapy consist of for people who struggle to find the right word or struggle to speak? What does speech therapy involve?

Lauren Westby: Speech and language therapy aims to improve the person's ability to communicate by restoring as much language as possible. So, teaching how to make up for lost language skills and then maybe finding other methods of communication, we typically try and find a modality of language that's not impacted, for example, use of gestures or communication boards. Drawing and writing can be effective tools. For people who have more mild impairments, we might do things like script training. So, script training is picking maybe a specific area that would be the most effective for being able to communicate in a specific situation. So for example, I'm actually using script training now to help one of my patients. In conjunction with the communication board, I have him say, "I need," and then use the communication to point to what his needs are.

Host Amber Smith: I've read that some people with aphasia resist going out in public -- they're very self-conscious -- and I wonder if becoming isolated has an impact on the symptoms or their ability to recover anything?

Lauren Westby: Communication requires practice, so it's important to continue to utilize the skills that are learned in therapy. But it is hard for a person with aphasia to want to communicate; it can hinder that. But they may benefit from participating in local support groups, aphasia groups, and ongoing therapy.

Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith, talking with Lauren Westby, a speech-language pathologist at Upstate.

Congressional Rep. Gabby Giffords developed aphasia after she was shot, more than a decade ago. And she's written about the challenge of speaking and how she often, still, to this day, drops prepositions and conjunctions, small words -- such as "in," "on," "and" -- that help hold a sentence together. Why are those particular words hard for someone to remember?

Lauren Westby: In aphasia, you can have difficulty with using basic grammar, ordering of words and difficulty with sentence structure. It's actually a common feature and people with aphasia, especially Broca's, so that nonfluent aphasia. People with aphasia are often able to use content words, like nouns and verbs, like when looking at a picture, they might be able to say the word "tree" or "car," but will have trouble with other small words that complete the sentence or thought.

Host Amber Smith: Bruce Willis was in the news recently when his family announced that he had aphasia. And it made me wonder about the job of an actor, having lines to memorize, maybe that would not be possible for someone with aphasia.

Are there other jobs that people with aphasia would still be able to do?

Lauren Westby: In general, it can be very debilitating, but we also in therapy are working to find a way for them to communicate the most effectively. So sometimes that script training that I was talking about can be really useful in those areas. Maybe being able to use a certain amount of communication or words to be able to participate in a vocational skill can be really helpful. But yeah, there are certainly many areas that people with aphasia can continue to work. It doesn't sound like there's anything a person can do to prevent aphasia.

Well, I think that might be a good plug for (the stroke-warning acronym) FAST, since stroke is actually the highest, correlating factor for aphasia: 25% to 40% of people who have strokes have a type of aphasia. So making sure that you're using those symptoms of FAST, so Facial drooping, Arm weakness, Speech slurring and the importance of Time in getting to the hospital.

Host Amber Smith: Good point. How would you suggest loved ones communicate with someone who has aphasia? Does speaking slowly help?

Lauren Westby: It can. That's actually one of the recommendations, is to speak slowly. A lot of times eliminating background noise or extraneous noise can be really helpful, keeping your language pretty short, but not condescending, writing down key words if their ability to read is preserved. Also, making sure you have their attention before speaking can be helpful, and allowing them an opportunity to formulate their thoughts. But I think also it's important to think about other ways to communicate, and to use context to help, also any kind of modality of language that might still be preserved may be helpful.

So, incorporating more writing or gestures, any kind of context in the environment, can be really helpful for helping communication.

Host Amber Smith: So, email or texting -- would that maybe help with being able to stay in touch with someone who has trouble speaking, but still wants to communicate?

With texting, it may be actually similar to how their output is. So if their language output is the same as their writing, then being able to write a text message may be just as difficult. What about how important is it to speak in person, so that they can see you, versus over the phone?

Lauren Westby: It probably is a lot easier because they can use a lot of different components of our communication to help with their understanding. So actually 93% of our communication is nonverbal, so they're going to use things like facial expressions, context cues, as well as gestures to help them understand the language. Also being able to look at your mouth can be helpful.

Host Amber Smith: When you, as a speech therapist, are working with someone who's recovering from a stroke and has got symptoms of aphasia, it seems to me that the progress might come in increments. Do you ever find yourself in the position where you're having to, along with teaching the speech therapy, teach patience?

Lauren Westby: You mean like family and friends?

Host Amber Smith: And the patients themselves. I mean, I imagine it must be frustrating to want to be able to speak and struggle and you're trying to do what the speech therapist prescribes, and if it doesn't come easily or quickly, it's got to be frustrating.

Lauren Westby: I think this also ties back to, you know, not a lot of people understand aphasia. So they're coming in with a stroke, and all of a sudden it's hard to be able to communicate, but "Why? I didn't know that that was a symptom of a stroke." And so the importance of education to both the patient and family and friends is extremely important.

Host Amber Smith: Before we wrap up, let me ask you once more to go over the different types, or the main types, of aphasia and the symptoms of each one.

Lauren Westby: There are distinctly three different types of aphasia. So the first is more of a nonfluent aphasia. So with nonfluent aphasia, or Broca's aphasia, -- people with this type of aphasia, they understand what other people say better than they can speak. They typically will struggle to get their words out, speak in very short sentences and omit words. They may be more aware of these impairments and become frustrated.

Fluent aphasia, also called Wernicke's: They may speak easily and fluently. However, the sentences that they're producing often don't make sense. They often don't understand spoken language as well, and often don't realize that others can't understand them.

And then global aphasia, all the modalities of language are affected. They may lose almost all language function, and they may speak in single words or not be able to speak at all.

Host Amber Smith: Do you see crossover where you might have a patient who has a lot of symptoms of one type and maybe some symptoms of other types as well?

Lauren Westby: Sure. I think we have these distinct categories, but I also think that sometimes you can see maybe somebody who has more of a receptive language deficit, fluent Wernicke's aphasia. They may still be progressing and especially in an acute rehab setting. And so the comprehension is improving. And then in global aphasia, same thing, they can still be progressing through. So we may see more expressive deficits, and then receptive language is improving. Or we may see that receptive language is improving and expressive language is not.

Host Amber Smith: Ms. Westby, this has been very informative, and I really appreciate you making time for this interview.

Lauren Westby: You're welcome. Thank you for having me.

Host Amber Smith: My guest has been speech-language pathologist Lauren Westby from Upstate's department of physical medicine and rehabilitation.

"The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe. Find our archive of previous episodes at upstate.edu/informed. This is your host, Amber Smith, thanking you for listening.