Aphasia: Tracing through the mysteries of a language disorder
Aphasia is a language disorder, typically occurring post stroke or head injury. In simple terms, aphasia results due to lack of blood supply to the regions of the brain associated with language which are primarily located on the left half or the left hemisphere of the brain. Other causes include tumors of the brain, infections, or degenerative disorders affecting the brain. Aphasia does not necessarily translate to a loss of language skills, but affects the ability to access these skills. It affects an individual’s ability to communicate effectively. It is more prevalent in older adults. However, childhood aphasia of speech can affect younger children as well. Aphasia can broadly affect an individual’s ability to comprehend another individual’s speech, express oneself, or both. One or more domains of communication, including reading, writing, speaking could be affected as a consequence of aphasia depending upon the areas of the brain involved and the severity of the disorder.
There exist many different classification systems for aphasia. The most widely accepted system is the Boston classification system (see figure) which broadly classifies aphasia as fluent or non-fluent aphasia. It is further classified by the person's ability to comprehend or repeat spoken language. Wernicke's and Broca's are the most common types of aphasia. Individuals with Wernicke's aphasia find it difficult to comprehend speech. Their speech is fluent but lacks content or meaning. Individuals with Broca's aphasia can comprehend speech but their speech is often halting, effortful, containing shorter utterances.
( The figure is based on the Boston classification system for aphasia )
Primary progressive aphasia is another type, affecting the geriatric population, which presents as a slow decline of language skills, secondary to other progressive neurodegenerative conditions of the brain such as Alzheimer’s disease .
The symptoms or signs indicating aphasia depend on the areas of the brain affected. Some cases show spontaneous recovery within 6 months or a year, with the language skills slowly showing an improvement. In other instances, the patient can have long lasting language deficits which can last a lifetime. Some of the common symptoms include inability to comprehend what someone is saying, inability to express oneself in an intelligible or understandable manner, using circumlocutions i.e. using another word or descriptions of the word when unable to express the desired word, using perseverative utterances i.e. repeating the same word instead of the appropriate word, using paraphasia's i.e. substituting the desired word with a wrong syllable or word, or using neologisms which are completely new made up words. Patients might have other associated conditions affecting speech and language such as dysarthria and apraxia of speech along with aphasia. Dysarthria affects the ability to speak intelligibly/clearly due to speech muscles being affected. Apraxia of speech affects the ability to program and execute speech. These conditions have different medical and rehabilitative approaches.
The patient usually undergoes a medical evaluation and receives treatment for the underlying cause. Once the individual is medically stable, other professionals are involved, depending on the individual’s areas of deficit. A holistic approach is adopted in most cases, with a multidisciplinary team involving the neurologist, general physician, occupational therapist, physiotherapist and psychologist along with a speech language pathologist. Aphasia specifically often falls under the domain of a speech language pathologist. A speech pathologist conducts assessment of the language and speech areas affected and adopts the best therapeutic approach suitable for the patient. The evaluation procedure mainly aims at documenting the individual’s difficulties in terms of both language and speech and also classifying the type. The type of aphasia is often not consistent throughout. As the patient improves, with therapy as well as due to the brain's capacity to regenerate lost connections, individuals can be moved to different categories. In the initial stages, most of the patients show characteristics of global aphasia, with extreme difficulty to communicate. As they improve, they show more characteristics of Wernicke’s or Broca’s aphasia and eventually reach anomic aphasia, which is often only a difficulty in retrieval of names. This need not be the case with all patients but is an often noticed trend as the patient receives therapy and improves.
The major aim of therapy is to make the patient as independent as possible, within the limits of their disability. Therapeutic approaches involve simple activities aimed at regaining speech and language functions and providing a means to communicate their needs. In some cases, individuals might be suggested the use of alternative and augmentative communication (AAC). AAC ranges from use of simple hand gestures, drawings etc. to the use of devices generating text or speech. It can be used as an alternative way of communication, in case of severe communicative disability or to augment communication especially in the initial stages, when the person has severe inability to communicate.
As a speech therapist, I see patients who have been through a lot of emotional upheaval and are exhausted from the medical treatments when they arrive at the clinic. Counselling therefore forms the core of the initial stages of therapy, involving both the patient and their family. In fact, the family members need a lot of emotional support and guidance, since this is such a new, unprecedented situation for them. Accepting that the patient will improve has a major effect on how effective the therapy would be. During my interactions with patients, I often come across patients who were a financially contributing member of the family. The sudden turmoil places them in a situation of helplessness and frustration from not being able to do their day-to-day activities and contribute to their family and society. Once they accept their situation and their speech begins to improve, they naturally gain more confidence. Consistency in following up with the therapy sessions is a major predictor of whether the outcome would be positive.
Awareness regarding speech therapy and its availability is a major issue that affects the accessibility of services in our country. There’s more awareness in the urban areas, but knowledge about the field is still very vague. In a lot of situations, people tend to accept their speech and language deficits as their fate, and do nothing more about it. There needs to be more advocacy, not just from the members of the field of audiology and speech language pathology, but the medical and rehabilitative field as a whole. Ultimately the patient’s quality of life will be poor if the right services are not made accessible. A good way to understand the importance of speech would be to draw a parallel with the current situation of the pandemic. A lot of us have not been in a position to socialize and communicate as much as we did before and that has affected our mental well-being and productivity. That is often the situation faced by an individual with a communication disorder. Communication is the essence of living, a basic right conferred by default at birth, and when such an essential ability is taken away, it is extremely frustrating. It is the need of the hour to make the services of speech language pathologists more accessible, and develop better policies in that direction.
Some common misconceptions and mistakes in understanding persons with aphasia :
Their intelligence is not affected. In the initial stages, their orientation and awareness would often be affected as well as certain domains of cognition such as memory could be affected but it cannot be correlated to their intelligence level.
Talk to them. Do not abandon them. Communication is an intrinsic need. Speech and language at the core are verbal behaviors that ultimately improve with practice, whether it’s a young child just starting out with their first words or an older adult who has lost it temporarily.
It is not a permanent loss. It’s a temporary inability to access language which improves over time with the right rehabilitative approaches. The extent to which speech and language will be regained varies with each individual, but an improvement is imminent if the right approaches are adopted.
The extent and severity of communication handicap is not the same for everyone. It affects each individual in a different manner. It is important to therefore tailor-make the rehabilitation program for each person.
If the right intervention is provided on time, an aphasic individual can eventually get back to living their life, as they did before. Timely intervention is a crucial aspect that ultimately decides how soon an aphasic individual can get back to communicating without difficulty with their loved ones and doing the things that they love.
About the Author:
Bhavani Venkatachalam is currently pursuing her Master’s degree in Speech Language Pathology from All India Institute of Speech and Hearing, Mysuru. She has completed her Bachelor’s degree in Audiology and Speech Language Pathology from Topiwala National Medical College, Mumbai and is an RCI certified Speech Language Pathologist. She has experience in working with the younger and the older population with disorders of language, speech, swallowing, and hearing disorders. Apart from being a speech therapist, she also likes to try her hand at photography, writing, cooking and playing guitar in her free time.