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According to the survey responses of speech pathologists working in palliative care, the role a speech pathologist can include the assessment and management of speech disturbances in palliative care caseloads*. Speech disturbances of a neurologic origin include motor speech disorders, such as dysarthria, apraxia and dysphonia. Other speech disturbances of neurologic origin include stuttering-like behavior, ecolalia, palilalia, speech attenuation, disinhibited vocalization, aprosodia, aphasia-related speech disturbances, mutism and pseudoforeign accent (Duffy, 1995). Speech disturbances of non-neurologic origins can result from musculoskeletal deficits, such as following laryngectomy (Duffy, 1995). Dysphonia can have non-neurologic origins including vocal abuse and neoplasms (Colton & Casper, 1996).
- Conditions associated with speech disturbances
- Assessment
- Intervention
- References
Conditions associated with speech disturbances
Conditions that may be associated with speech disturbances in palliative care caseloads include:
Speech Disturbances of Neurologic Origin Parkinson's Disease:
Individuals diagnosed with Parkinson's disease (PD) commonly report speech/voice problems involving difficulty initiating speech, imprecise articulation, weak voice, hoarse voice and monotonous voice (Hartelius & Svensson, 1994; Regnell, 2003).
These speech disturbances are characteristic of hypokinetic dysarthria, a common speech disorder associated with PD (Duffy, 1995). According to Klasner and Yorkston (2000), "Although the prevalence of communication problems in Parkinson's Disease is high, the disorders are frequently not severe enough to prevent the use of natural speech in many or all communication situations" (p. 257).
Motor Neurone Disease/Amyotrophic Lateral Sclerosis:
Amyotrophic lateral sclerosis (ALS) accounts for 80% of cases of motor neuron disease (Caroscio, Mulvihill, Sterling, & Abrams, 1987, as cited in Mathy, Yorkston, & Gutmann, 2000).
According to Duffy (1995) "the dysarthria of ALS may be flaccid, spastic, or, most often, mixed flaccid-spastic" (p. 245). In the advanced stages of the disease, flaccidity generally becomes more prominent (Yorkston, Beukelman, Strand & Bell, 1999). All aspects of the speech system can be affected. Dysarthric characteristics vary according to the prominence of spasticity or flaccidity (Yorkston et al., 1999).
Amyotrophic lateral sclerosis can be associated with respiratory failure. Individuals with the disease may have to make a decision as to whether to receive a tracheostomy and/or mechanical ventilation (Yorkston et al., 1999). Tracheostomy has implications for the production of voice/speech (see TRACHEOSTOMY section of website).
Huntington's Disease:
Huntington's disease (HD) impacts significantly on an individual's ability to communicate. In the late stages of the disease individuals are often unable to use verbal communication (Folstein, 1990, as cited in Klasner and Yorkston, 2000). Individuals with HD can experience hyperkinetic dysarthria which is characterized by involuntary movements of speech, face and respiratory muscles (Yorkston et al., 1999).
Multiple Sclerosis:
Dysarthria is uncommon during the initial stages of multiple sclerosis (MS) (Duffy, 1995). However, as the disease progresses the prevalence of dysarthria increases (Yorkston et al., 1999) According to Duffy (1995), the dysarthria associated with MS may be classified as any single or mixed type of dysarthria. There are also rare instances in which an individual with MS may experience apraxia of speech (Duffy, 1995). Other progressive neurological diseases are also associated with speech disorders including multiple systems atrophy (MSA) and Alzheimer's disease (Duffy, 1995).
Non-Neurological causes of Speech Disturbances Cancer:
In a study by Forbes (1997) of 38 palliative clients with head and neck cancer, 53% of participants indicated that communication was a problem. Salt and Robertson (1998) conducted a study of communication impairment in hospice inpatients with cancer. It was found that "most participants had impaired lip and tongue mobility and reduced breath control, resulting in dysarthric sounding speech and dysphonia" (p. 98).
Structural Deficits:
Clients with cancer of the head and neck in palliative care may have a laryngectomy or tracheostomy. This has implications for the production of voice or speech (see TRACHEOSTOMY and LARYNGECTOMY sections of this website). Other conditions associated with Speech Disturbances in Palliative Care:*
- Traumatic brain injury
- Stroke
- Infectious processes, such as HIV AIDS, Polio
- Ageing without a terminal illness
- Restrictive and obstructive airway diseases, such as
Chronic Obstructive Airway/Pulmonary Disease and pneumonia
- Tumours of the brain or head and neck region
Assessment
A search of the literature regarding palliative care revealed a limited amount of information regarding the assessment of speech disturbances in this field.
Speech pathologists experienced in palliative care have reported using the following speech assessment tools/procedures in their palliative care work*: Frenchay Dysarthria Assessment (FDA) (Enderby, 1983)
The FDA can be used to assess the speech of palliative clients with neurological speech disturbances*. According to Duffy (1995), the FDA is the only standardized published test which "quantifies dysarthria in a manner that distinguishes among dysarthria types" (p. 87). The assessment involves self-report and observation of reflexes, respiration, oromotor function, intelligibility and rate. The FDA requires the completion of tasks designed to assess certain parameters of speech (Duffy, 1995).
Informal assessment (via observation and interaction)
Informal or observational assessment procedures vary among clinicians and may involve the following*:
Acquiring and examining case history information
Non-speech oromotor examination or bulbar assessment
Assessment of speech characteristics including voice, articulation, respiration, rate, and intelligibility
Analysis of type of motor speech disturbance* (i.e. type of dysarthria or dyspraxia) (Duffy, 1995)
Survey responses of speech pathologists experienced in palliative care indicated that it is primarily informal methods which are used to assess speech in palliative care*. No clinician surveyed indicated the use of instrumental measures to assess speech.
Formal tools/procedures available (to speech pathologists) for assessing speech disturbances include the following:
- Assessment of Intelligibility of Dysarthric Speech (Yorkston & Beukelman, 1981)
- Apraxia Battery for Adults (Dabul, 2000)
- Dysarthria Profile (Robertson, 1987)
- Perceptual Voice Profile (Oates & Russell, 1997)
However, it must be noted that these specific assessment tools were not mentioned in the survey responses by speech pathologists working in palliative care*. Formal assessment may also not be appropriate with palliative cases, considering the focus of care is on maximising the client's quality of life.
Intervention
It is important to establish appropriate and functional communication systems to meet client's current and anticipated communicative needs and goals (see COMMUNICATION section of this website; Balandin, 2003). This requires ongoing assessment of communicative competence and changes in functioning as well as consideration of the natural course or progression of the disease (Beukelman & Yorkston, 2000; Beukelman & Mirenda, 1998)
The goal of speech intervention in palliative care is thus the maintenance and facilitation of effective communication (Pollens, 2004; Salt, & Robertson, 1998).
Speech pathologists who work in palliative care provide intervention for speech disturbances in the form of education and advice for the client, their family or friends and staff*. This education may cover:
- The nature and cause of the speech disturbance
- The impact of the speech disturbance on communication
- Anticipated changes in the client's speech
- Alternative and augmentative communication (AAC) options
- Compensatory strategies
Examples of such strategies includes:
- Adjusting position
- Speaking face to face
- Minimising distractions
- Adjusting lighting and noise levels
- Clear speech strategies* for example, speaking loudly and slowly to reduce slurring of speech
(Yorkston, Miller & Strand, 1995)
Speech Pathologists who work in palliative care also provide intervention in the form of augmentative and alternative communication (AAC)*. According to Klasner and Yorkston (2000), "AAC management is central to palliative care" (p. 263). Various methods of AAC may be used to provide an effective means of communication for palliative clients who no longer have functional speech. Intervention involving AAC requires consideration of the following:
- The client's medical condition
- Cognition, vision, hearing, and physical status
- Literacy levels and vocabulary
- Communicative needs and competence (current and anticipated)
- Potential barriers to communication
- Level of experience with technology
- Patient wishes
(Beukelman & Mirenda, 1998).
Speech pathologists working in palliative care reported using the following AAC interventions*:
- Drawing, writing
- Alphabet board
- LightWRITER (Visual and voice output electronic communication aid)
Additional AAC interventions that could also be used in a palliative care setting include:
- Unaided systems
- Non-verbal vocalization
- Gestures, mime, body language
- Sign or signaling
- Aided systems
- Visual or auditory scanning, eye gaze boards
- Communication board or book, chat book
- Request cards
- Other visual and/or voice output communication aids
- Electrolarynx
(Beukelman & Mirenda, 1998)
- Voice amplifiers (Salt & Robertson, 1998)
- Talking mats (Murphy, 1998)
For more information regarding AAC intervention see:
- COMMUNICATION section of this website
- Beukelman, D. R., & Mirenda, P. (1998). Augmentative and Alternative communication: Management of severe communication disorders in children and adults (2nd ed.). Baltimore: Paul H. Brookes Publishing Co.
- Beukelman, D. R., Yorkston, K. M., & Reichle, J. (Eds.). 2000. Augmentative and Alternative Communication for Adults with Acquired Neurologic Disorders. Baltimore: Paul Brookes Publishing Co.
References
Balandin, S. (2003). Functional communication - not a last resort. Acquiring Knowledge in Speech, Language and Hearing, 5(1), 10-12.
Beukelman, D. R., & Mirenda, P. (1998). Augmentative and Alternative communication: Management of severe communication disorders in children and adults (2nd ed.). Baltimore: Paul H. Brookes Publishing Co.
Beukelman, D. R., & Yorkston, K. M. (2000). Decision Making in AAC Intervention. In D. R. Beukelman, K. M. Yorkston & J. Reichle (Eds.), Augmentative and Alternative Communication for Adults with Aquired Neurologic Disorders (pp. 55-82). Baltimore: Paul Brookes Publishing Co.
Colton, R. H., & Casper, J. K. (1996). Understanding Voice Problems. A Physiological Perspective for Diagnosis and Treatment (2nd ed.). Baltimore: Willams and Wilkins.
Dabul, B. (2000). Apraxia Battery for Adults (2nd ed.). Austin: Pro-Ed.
Duffy, J. R. (1995). Motor Speech Disorders. Substrates, Differential Diagnosis and Management. St.Louis: Mosby.
Enderby, P. (1983). Frenchay Dysarthria Assessment. San Deigo: College-Hill Press.
Forbes, K. (1997). Palliative care in patients with cancer of the head and neck. Clinical Otolaryngology, 22, 117-122.
Hartelius, L., & Svensson, P. (1994). Speech and swallowing symptoms associated with Parkinson's disease and multiple sclerosis: A survey. Folia Phoniatrica et Logopaedica, 46, 9-17.
Klasner, E. R., & Yorkston, K. M. (2000). AAC for Huntington's Disease and Parkinson's Disease: Planning for Change. In D. R. Beukelman, K. M. Yorkston & J. Reichle (Eds.), Augmentative and Alternative Communication for Adults with Aquired Neurologic Disorders (pp. 233-270). Baltimore: Paul Brookes Publishing Co.
Mathy, P., Yorkston, K. M., & Gutmann, M. L. (2000). AAC for Individuals with Amyotrophic Lateral Sclerosis. In D. R. Beukelman, K. M. Yorkston & J. Reichle (Eds.), Augmentative and Alternative Communication for Adults with Aquired Neurologic Disorders (pp. 233-270). Baltimore: Paul Brookes Publishing Co.
Murphy, J. (1998). Helping People with Severe Communication Difficulties Express their Views: A low-tech tool. Communication Matters, 12, 9.
Oates, J., & Russell, A. (1997). Perceptual Voice Profile. A Sound Judgement. (CD ROM).
Pollens, R. (2004). Role of the Speech-Language Pathologist in Palliative Hospice Care. Journal of Palliative Medicine, 7, 694-702.
Regnell, M. (2003). Speech pathology and parkinson's disease in the home environment. Caring, 22(1), 20-22.
Robertson, S. J. (1987). Dysarthria Profile. Tucson: Communication Skill Builders.
Salt, N., & Robertson, S. J. (1998). A Hidden Client Group? Communication Impairment in Hospice Patients. International Journal of Language and Communication Disorders, 33, 96-100.
Yorkston, K. M., & Beukelman, D. R. (1981). Assessment of Intelligibility of Dysarthric Speech. Tigard: CC Publications.
Yorkston, K. M., Beukelman, D. R., Strand, E. A., & Bell, K. R. (1999). Management of Motor Speech Disorders in Children and Adults (2nd ed.). Austin: Pro-Ed.
Yorkston, K. M., Miller, R. M., & Strand, E. A. (1995). Management of Speech and Swallowing in Degenerative Diseases. Tucson: Communication Skill Builders. |
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