While the underlying causes of aphasia and dementia are distinctly different, the two conditions have a number of similarities. Clinicians may use the same therapy techniques for both patient populations, but the treatment goals will vary.
The root deficit of aphasia is a problem with access to the language system. Patients also may present with some cognitive deficits.
"This is a population with brain damage," said Scott Rubin, PhD, CCC-SLP, an associate professor in the Department of Communication Disorders at Louisiana State University Health Sciences Center in New Orleans. "It affects language as well as some of the things that might go along with brain damage, like attention and memory problems."
Rather than having trouble with words, patients with dementia may primarily have difficulty understanding and defining concepts. Primarily an intellectual disorder, dementia is rooted in cognitive deficits.
"We need to think about what we're treating," Dr. Rubin told ADVANCE. Clinicians cannot concentrate only on language and neglect subtle conceptual issues.
Both patient populations may use circumlocution to search for words or concepts. However, this self-cueing technique reveals differences between the two conditions. Patients with aphasia eventually may reach their target, while those with dementia frequently end up much further away from it.
"The person with aphasia can maintain the conceptual underpinning for the target, activate the related lexical memory, and then access the word," said Dr. Rubin. "People with dementia diverge from their original conceptual idea to different thoughts and intentions, so it may be harder to get at the root of what they're trying to convey."
Speech-language pathologists need to tune into the information that neuropsychologists glean from their evaluations. In addition to the language aspects of the conditions, they must consider attention and conceptual-based information, noted Dr. Rubin. "Sometimes we focus our evaluation and treatment on the language aspects and don't consider what else could be going on with the patient."
Aphasia is primarily a language-based disorder because the language areas of the brain are damaged, "but there's a lot more to treat," he said, due to the changes in workload and resource allocation in the brain.
For example, if a stroke damages the perisylvian region in the left hemisphere of the brain, where many language operations occur, other areas of the brain attempt to compensate for the loss. Language function may shift to the right hemisphere through therapy and recovery. However, the brain can only do so much. The right hemisphere, which handles a lot of attention and memory issues, may become weaker if it lacks sufficient resources.
"Those functions in the right hemisphere are not wiped out, but they might undergo subtle changes in patients with aphasia because the brain is trying to do that information and take on new information," said Dr. Rubin.
Therapeutic interventions for the memory problems in patients with dementia and the language deficits in patients with aphasia should begin with simplifying syntax and providing limited information to promote comprehension.
In dementia the communication partner should include breaks between utterances to verify that the patient has received the information. Breaks also should be provided for individuals with aphasia, but these are geared more toward reducing noise build-up or language input, as too much can cause a breakdown in communication.
Preventing communication breakdowns is a key goal for individuals with aphasia who are returning to work. Clinicians should introduce tasks that deal with divided, focused and alternating attention.
"We often alternate between communication tasks as things are going on around us," Dr. Rubin said. "To get patients in the best shape for dealing with that kind of situation, we have to specifically address alternating attention so they can maintain the thought while shifting between tasks."
Clinicians may use the same therapy techniques for patients with dementia and aphasia, but the target will be different. The goal is to reduce the memory load among patients with dementia, while the goal for patients with aphasia is to reduce the language load.
"I'm not saying that to improve comprehension we're focusing strictly on memory for the patient with dementia or on language for the patient with aphasia. But when we're doing things like simplifying syntax and reducing the amount of information, we should do it with the idea of what it is we're targeting," he said.
Speech-language pathologists can perform an array of tasks, such as storytelling and descriptions, to determine what they need to target. For example, during description tasks, the clinician can listen for the number of words produced or the amount of new information offered.
They can gauge attention through sorting tasks, noting whether patients drift off course and the amount of time it takes. They also can observe whether their storytelling skills are cohesive. For that task clinicians may focus on a patient's grasp of grammatical structure, the meaning of the messages the person is trying to convey, and the amount of information given.
For patients with dementia, speech-language pathologists have an ongoing role in language and cognitive stimulation, periodic evaluation, and the re-education of family members and caregivers regarding appropriate communication techniques.
While daily speech intervention may be effective in dementia, daily cognitive stimulation may be counterproductive as a result of fatigue and the overall frailty of a person's neurological system.
"This may be controversial, but there have been hyperstimulation studies in which clinicians overly stimulate the patient with dementia and get them to a state of high arousal," said Dr. Rubin.
While this technique has shown to improve the patient's awareness of the environment, the effects do not appear to be long-lasting.
Other data have shown that daily stimulation in the form of guest speakers, arts and crafts, and music are beneficial. "These things stimulate patients. It's good for their quality of life because they communicate and interact with other patients and professionals," he noted.
When working with individuals who have dementia, speech-language pathologists often concentrate on staving off their lack of connection with the environment.
"The earlier stages of dementia are the most painful for the patient," explained Dr. Rubin. "It's the opposite for the family. The earlier stages are more comforting for them because they can still interact readily with their family member."
In the initial stages "patients know they've been diagnosed with probable Alzheimer's, and they know what's ahead," he said. "We try to keep them as interactive and productive as possible. There will likely come a time when they become less aware and less intellectually concerned about their state."
The tables turn in the later stages. Family members see just "the shell of their loved one," and patients lose their connection, Dr. Rubin said.
Because the natural courses of dementia and aphasia are so different, it's important to draw a line between the treatment processes.
Clinicians working with patients who have aphasia will do what they can to optimize gains in recovery and remain positive with the families about what they can expect. "Functional communication is the gold ring that we're reaching for," Dr. Rubin said.
Patients with aphasia are relatively intact cognitively and intellectually and can still appreciate seeing a grandchild graduate from high school or college, while individuals with dementia deteriorate.
"One is facing continued life with somewhat diminished communicative abilities, and the other is facing diminished communication and life," said Dr. Rubin.
For More Information
Scott Rubin, PhD, (504) 568-4350, e-mail: SRubin@lsuhsc.edu
Jason Mosheim is an Associate Editor for ADVANCE. He can be contacted at firstname.lastname@example.org.