I was looking into the recent SLT literature for stroke recently, and my very learned friend (who still works in academia) pointed me towards a new RCT about SLT for aphasia and dysarthria in the first four months after stroke.  “Hurrah”, I thought, “maybe the medics will start taking us seriously when we can point at our own set of RCTs”.

Here it is, freely available in full text:

Effectiveness of enhanced communication therapy in the first four months after stroke for aphasia and dysarthria: a randomised controlled trial

The authors recruited people with aphasia or dysarthria following stroke, starting treatment about 17 days after their stroke.  Half the group got best practice but realistic speech and language therapy over the next four months and half got visits from untrained visitors who did unstructured daily activities, mostly conversation.  They compared outcomes at around 6 monthsprimarily by looking at functional communication measured on the TOMs activity scale.

Much to my horror, they found no difference in functional communication outcomes between the two groups.

That’s pretty stunning when you consider that as therapists, we would mostly love to be able to offer communication therapy a couple of times a week with as much impairment work as these participants received.

So what now?

Before we get too upset, it’s worth looking more closely at the study.

I salute and applaud the authors for trying to do the impossible, but there are big problems with RCTs in Speech and Language Therapy as a general service.

  • They lumped dysarthria in with aphasia (though their wording suggests they didn’t mean to – ooops).  These are two very different disorders, and even within aphasia there are many different subtypes.  It’s reasonable to expect that these would have different prognoses for recovery and different responses to treatment.
  • The therapy they provided was very mixed.  Perhaps this is a result of trying to treat all the different impairments, or perhaps it is simply a reflection of what we do as therapists, but it makes it hard to say what you are testing.
  • The volunteers also all did different things.  Maybe they were doing something that was effective, but we don’t know what.
  • They tried to use functional outcome measures.  I agree with this in theory – no point in improving someone’s ability to point at something and say ‘giraffe’ unless they’re something they were keen on being able to do.  However, when you use an 11 point scale that is rated by therapists watching you communicate with an unfamiliar listener, it’s not going to be very sensitive.  There may have been improvements that were not detected.

This article annoyed my friend so much that she wrote a rapid response and concluded that “this is an issue that can only be addressed by targeted studies that use sensitive outcome measures for well-defined therapy approaches for specific communication disorders.”

As a therapist, why should I care?

It’s hard to know what I should take away from this study.  I do think there are significant problems with it, but I’m not sure those problems completely explain away the fact that there was no difference between therapy and an attention control.

One thing we can know for sure is that the people who commission speech and language therapy services will read studies like this and we need to know how to respond.

I will certainly be aiming to make my therapy more functional and worrying less about not doing ‘real’ impairment level therapy unless I’m convinced that there’s evidence for it.

It also puts a certain amount of urgency behind the gradual increase in focus on outcome measures and outcome based commissioning.  If we don’t have research that says we’re effective then we either need to be able to show it at the level of our service or change what we do.

Karen Bryan‘s tips for communicating in dementia

  • Keep language concrete
  • Use contextual cues – have an object in front of you if you are talking about it
  • Slow down if you are speaking too fast
  • Do not slow down your speech too much, because natural intonation patterns help comprehension
  • Establish a normal two-way dialogue as far as possible
  • Don’t focus only on information exchange – value the dialogue as an interaction
  • If the person with dementia raises a topic, pick the most important word and give the person an opportunity to talk positively about that subject
  • Do not explicitly correct

(This is the lady behind the Barnes Language Assessment, the Right Hemisphere Language Battery, the SPPARC – how much has she changed your practice?)

Nursing Staff talking about how they communicate with people with dementia (from the Christie Hospital in Manchester)

  • Introduce yourself every time, because people may hold on to what is happening in the moment, but not remember some time later
  • State your role each time, because they may not be able to interpret your meaning
  • You assess understanding all the time – look at body posture, eye direction, body movements – and you modify your communication accordingly
  • Don’t assume they don’t understand
  • Language may fluctuate
  • Reasoning may be problematic.  In this case, trying to reorientate people to where they are and what is happening may simply be distressing.
  • Don’t overload with information
  • Use environmental cues – brightly coloured toilet doors
  • Emotion may be present when logic may not.  People may not respond to reasoning, but emotional responses need to be acknowledged.
  • Is their behaviour unacceptable to them or to you?  Validation of feelings and being allowed to carry out behaviours that may be socially unusual but are not dangerous may lead to calmer moods.

Culled from Word of Mouth on Radio 4 on 31 July 2012.

Word of Mouth on Radio 4 today was about carers and language, and I already spoke about it a bit here.  It was such a goldmine of interesting discussion that it deserves a second post, looking at their discussion of hearing impairment and dementia.

They start off by saying that hearing problems can compound the communication problems in dementia.  So far this isn’t surprising, as anyone with a hearing impairment will have increased difficulty communicating.

But if you have dementia, your ability to process information coming in may have slowed, but the rest of the world keeps going as fast as it always did.  You have to comprehend, remember what has been said, decide what you want to say and then respond.  By the time you get to where you can respond, the conversation has moved on.

It’s easy to see why people give up, especially when helpful communication partners fill in the gaps all the time.

With a hearing impairment, you have a double whammy.  You add an extra layer of time and difficulty to the comprehension of language.  So then poor understanding may not be purely due to the dementia, though everyone around you may assume that it is.  Giving a hearing aid may actually reduce the cognitive capacity required to comprehend and improve function.


As a therapist, why should I care?

  • It’s my job to reveal competence where possible, and distinguishing between sensory difficulties and comprehension difficulties is something I should be aware of.
  • It gives me cold shivers to think about how many people with dementia and poor hearing I see every week.

On the other hand, this is a complex issue – hearing aids are not a magic wand and they cannot restore hearing as it was, particularly in presbycusis (age-related hearing loss), because delicate inner hair cells that are lost as we age don’t just make sound louder.  There is often poor compliance with wearing aids and I am told that it takes a while to learn to get the best from them.  Add technical difficulties such as remembering to change batteries and suddenly they don’t seem like such a no-brainer.

I suppose the answer is the same as in many aspects of dementia care – you have to get in there early and get the person used to the dentures/hearing aid/communication aid while they are finding it relatively easy to learn.

But add another action point:

  • I can teach carers strategies for use with hearing loss even if the person with dementia is not going to be wearing a hearing aid.

I drove home today listening to the BBC Radio 4 program “Word of Mouth” presented by Chris Ledgard.  One part of the show talked about the language used by people with dementia and how that influences the language of people caring for them.

Alison Wray (Cardiff University) described one aspect of language in Alzheimers.  The brain is clever at taking shortcuts where it can.  For example, using highly automatic learned phrases  - ‘Let me see now . . .’ when searching for something – gives us a way of stalling when we’re using all the brainpower doing something else.  In psycholinguistic terms, these kind of formuleic phrases are thought to have become somewhat lexicalised, so that they have their own representation in the brain’s dictionary.  When you use them you just have to pull them out and they’re ready to go, without having to spend time assembling a whole new phrase.

If you have fewer resources available then this becomes an even better strategy, for example, when you have a reduced cognitive capacity due to dementia.  These formuleic phrases help people to maintain conversation when they wouldn’t be able to formulate their own language – using formuleic phrases to “patch the gaps”.  As Alzheimers progresses, you might see more and more formuleic phrases due to reduced cognitive function and repetitive language due to poor retention.  However, formuleic phrases aren’t always selected completely accurately, and may carry nuances of meaning that are not intended by the speaker.

Alison talked about how this affects communication with carers.  If the person you are looking after keeps saying the same thing, this becomes frustrating as it feels like a lack of engagement.  Then you feel guilty about feeling frustrated.  Over time, carers can start using formuleic language as well in order to disengage and avoid the frustration and stress of the person with Alzheimers not remembering things that are said.  But then there is a risk of a downwards spiral of disengagement, resulting in entirely superficial interactions, which aren’t satisfying for either person.

If you can help carers recognise this cycle and negative attitude towards language then you can help them behave in more supportive ways.

There are some good explanations of this material in an article written for the Canadian Modern Language Review here.

As a therapist, why should I care?

  • People with dementia can chat away using formuleic language they wouldn’t be able to construct themselves.  This gives a false impression of their expressive language abilities.
  • Because these formuleic phrases can sometimes be not quite right, it may also make them appear more confused than they really are.
  • Carers of people with dementia can react in unintentionally unhelpful ways by becoming formuleic themselves and not engaging with the emotions or intentions behind the interaction.
  • Other authors have suggested using the reliance on formuleic language as a strength in remeniscence work – using a written life story repetitively can help to trigger memories and aid discussions – examples in Clegg 2010.

Looking into this topic took me to the wonderful Trebus Project, which is a collection of life stories of people with dementia in their own words.  It’s more of an art project than a therapy pilot or a scientific study but wouldn’t it be a fantastic idea to use on a wider scale? It’s rather like reminiscence therapy, but more led by the person with dementia.

On the website, I really like Alison Wray’s comments on the “An Occasional Cobra” stories:

This input from David epitomises for me the importance of the work he has done with people like Shirley. Because he has taken her own story down, in her own words, he is able to feed back to her information at a level of detail that can help her reanchor herself into her own narrative. This harvesting of information, so it can be reinvested, is not only an effective means of scaffolding conversation with a person with Alzheimer’s, but a mark of tremendous respect to the person

Yes, that sounds like something I’d like to do as a therapist.

The Trebus project has a printed version of a subset of the life stories:

Clegg, D. (Ed.). (2010). Tell Mrs. Mill her husband is still dead. London: Trebus Project

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