On March 16, 2021, Robin Roope, the Clinical Speech Therapy Lead at Memorial Care Long Beach Medical Center, gave a presentation titled “Stroke, Aphasia, and Apraxia: Tips for Communication” via Zoom to the stroke survivors and caregivers who attend our support groups.
Robin began her presentation with a definition of aphasia. “Aphasia is when the language center of our brain has been affected by something. That injury could be from a stroke. Aphasia can affect both expression and comprehension (i.e., understanding).”
When somebody has aphasia, he or she might experience:
- Not being able to find the word. The stroke survivor may know the concept, but another word than the one intended pops out. That word may be something very similar to the target, but not the actual word. If the survivor is trying to say “pen,” he might say “pencil” instead.
- Not understanding the entire content. The person might comprehend a few aspects, but not all of it. This is especially true for lengthier information or directions with multiple steps.
Robin mentioned that there are different kinds of apraxia, but this presentation focused on apraxia of speech: “Apraxia of speech is not about language,” she said. “The person knows the word and tries to say the word, but the message from the brain to the mouth is affected. What comes out is not what was intended.” Apraxia of speech involves the motor planning behind what you are trying to say. Robin added that the person might say the target word correctly one minute, but the next minute may not be able to say it.
Tips for the Stroke Survivor with Aphasia or Apraxia of Expression:
- First and foremost, be patient with yourself. You are doing the best you can; it will take time to learn what works best for you.
- Sometimes you just need to stop and take a breath, especially if you have apraxia. Trying repeatedly to say the intended word can make the process harder. Sometimes the brain needs to reset, so pause, take a breath, and try again.
- Maybe you know the concept but can’t capture the correct word. For example, if you want to say the word “pen,” but “pen” doesn’t come to you, you can say “write,” or “pencil,” and your listener will get the gist of what you are trying to say.
- Communication isn’t just talking and speech. You use your hands in gesturing. Maybe you can’t say the word “write,” but you can use your hand to make the gesture of writing. That will give your communication partner an idea of what you are trying to say. Robin said, “Writing can be an asset for some people; for others, it might be drawing. We look at communication from all avenues.”
- For some people, having a “communication book” can be helpful. This type of book contains basic pictures of what you might want to communicate, for example a bed, a wheelchair, and a blanket. If you are cold and have trouble saying the word “blanket,” you can point to the picture of the blanket. (This does require that the person knows that there is a connection between being cold and needing a blanket.) Some family members create an individualized communication book that features very specific items. A caregiver can include a photo of the stroke survivor’s actual bed or toothbrush to personalize the communication book. To make this personalized communication book more efficient, the caregiver can categorize the pictured items by making sections in the book for Bathroom, Clothing, Family Members, Food, etc.
Robin stressed that “…there is no across-the-board theory or therapy that is best for every stroke survivor. Therapy should be individualized, based on the person’s needs, interests, and with whom he will be communicating.”
Tips for the communication partner (caregiver/family member):
- Be patient with yourself as well as with your loved one. You, like the stroke survivor, are trying your hardest to communicate. Take a breath. You know you are doing everything you can do. Just keep doing it.
- When communicating with the stroke survivor, do it face to face. If your back is turned, the loved one can’t see facial expressions, gestures, or pointing. Non-verbal communication is very important.
- Since communication for the stroke survivor requires a lot of energy, it is best to do it in an environment where distractions are minimized. Also, have your loved one maintain a good sleep/wake schedule. The brain needs time to reset and refresh.
- Break down an instruction into smaller parts. Give the first direction, then check for understanding. Then add the second direction, and check for understanding, and so forth.
- Try giving a demonstration of an action, so as to go beyond saying the word to acting out the concept.
- Give your loved one time to respond. You may know this person so well that you can verbalize her thoughts, but that can work against what you are trying to achieve. If the stroke survivor feels like her caregiver is going to finish her thought, she may stop trying to do the work herself.
- As with every aspect of caring for the stroke survivor, you don’t want to err on the side of enabling—doing for the stroke survivor what he can try to do for himself. However, watch for signs of frustration building. At that point, you can ask “Do you need help?” Or you can even say, “Let me know if you need help” when starting a specific communication. Let the stroke survivor be the one to determine if and when he needs help so as to honor his need to be in control of his own experience.
- Encourage gestures or pointing to a desired object/place (e.g., bathroom). You can say, “Can you show me what you’re trying to say?” This can provide relief to the stroke survivor struggling to find a word.
- When asking something, don’t use an open-ended question such as “What do you want to do today?” There are simply too many options for the person struggling to communicate. You can give a multiple-choice question: “Do you want to go to the park or to the grocery store?” Or, more fundamentally, ask a simple yes-or-no question, such as “Do you want to go to the park?” If the person answers “no,” you can ask, “Do you want to go to the grocery store?” Understand that as a person gets more tired, it becomes prudent to ask the yes-or-no variety, which is the simplest form.
- Watch for loved one’s frustration and fatigue. You can pause and come back to the communication session later.
Questions and Answers:
Question: Can a person have both aphasia and apraxia?
Yes, you can have both aphasia and apraxia; one might be more intense than the other.
Question: What are some things I can do to start the process of communicating effectively with my stroke survivor?
This will vary from individual to individual. In general, when we talk about the here and now, it can be easier than talking about the past or future or a distant place. The context of the environment is helpful. If I am talking about brushing your teeth and we are not in the bathroom, it may be harder for the stroke survivor to come up with the word “toothbrush.” So practice in the proper context.
Do some word games. These will vary depending on the stroke survivor’s communication deficits. For those who have difficulty thinking of words only periodically, try the board games Taboo or Catchphrase. For others who have more trouble, you can do a matching game using two words written on separate index cards and their corresponding pictures on two other index cards. The stroke survivor can match the proper word to the proper picture. Increase the possible number of matches accordingly.
Try communication apps such as Linguisystems, Lingraphica, and Tactus. Begin with the free versions, and if they prove helpful, you can purchase the more comprehensive versions.
Question: What can a stroke survivor do to practice reading, if reading is the deficit?
A caregiver of a person with aphasia or apraxia often asks, “Should I start with children’s books?” The answer is yes, but only if the stroke survivor is a preschool teacher or wants to read to her grandkids. Otherwise, use age-appropriate materials such as a newspaper, where you can first concentrate just on the headlines.
Will a “communication book” impede the stroke survivor’s ability to talk? In other words, will the survivor get dependent on a communication book?
No, if it’s used in the right way, a communication book can help, since using it will lessen the frustration in the moment. It can also greatly aid in language recovery and processing: the caregiver can identify the bed in the book by pointing to it and saying “bed,” then asking the stroke survivor to repeat the word.
Question: How do I get my loved one to play the suggested games or apps if he doesn’t want to do it?
If it feels like homework, the stroke survivor will be less likely to engage. Capturing real life situations will automatically lead to a practice session. At breakfast time, talk about what to eat or make a grocery list together.
Question: Is listening to audiobooks helpful to the stroke survivor if he follows along with the printed words?
Yes, if the person is able to keep up with reading along with the audio book. The caregiver should check in with the stroke survivor to see if he is able to follow along. Can the person recap the material? If the answer is no, you might have the stroke survivor listen in shorter segments.
For people not ready to hear a full novel, try Talkpath from Lingraphica. This app offers various topics, such as science or politics. The stroke survivor can choose a topic of interest, and the app will present him or her with a choice of articles. The content is presented as the written word, which can be followed as the audio is playing.
Question: How can I, as a stroke survivor, practice on my own when my caregiver is unavailable?
Utilize apps on your tablet or computer. For people with apraxia, Linguisystems offers an app that pairs a letter with its sound. For example, you will see the letter “m” and lips making the “m” sound. Then the app goes from letters to words. You can ask your caregiver to set up the app you want to try at any given time, so you can work it alone.
For other people, practice writing on your own. Have your caregiver write down a list of familiy names that you can practice writing your yourself.
If you can read, repeat the days of the week that are written on a list. If you can’t read, ask your caregiver to make a recording of the days of the week so you can practice verbalizing. Or ask your caregiver to record on your phone the names of family members. Play the recording and repeat the names. Practice makes proficiency.
Question: How do you know if something is too difficult for the stroke survivor, but he is not letting you know that?
Look for the level of frustration. If you see your loved one becoming more and more frustrated, it could be that the task is too challenging at this point. Or you know he is capable, but at this particular time, he is not responding. It may just be the time of the day, and the task is too difficult now, but will be easier later or the next day.
Question: Crossword puzzles and word searches have been recommended to my loved one. What if the stroke survivor doesn’t like to do crossword puzzles or word searches? What other activities can I offer?
Find things that your loved one enjoys. If a person likes gardening, look together at a magazine or garden center ad, and ask your loved one to look for and say the words for tools or other items needed for your garden. Or simply point at an item such as a hose and ask your loved one to say the word that describes the item.
Question: What about text messaging, where the stroke survivor’s texting comes out garbled?
Texting can be challenging, whether typing or using speech-to-text. Experiment with which of these two methods works best. You can also encourage the stroke survivor to use his tablet to text, rather than his phone, to make use of bigger letter keys.
Stroke Support Association thanks Robin Roope for her wonderful presentation, and all the many resources, tips, and techniques that she offered for use by both the stroke survivor and the caregiver.