The Royal Marsden Hospital Manual of Clinical Nursing Procedures - Lisa Dougherty [162]
Aphasia may be temporary or permanent. Aphasia does not include speech impairments caused by damage to the muscles involved with speech, that is, dysarthria.
Dysarthria is a motor speech disorder. Neurological and muscular changes may cause difficulty in producing or sustaining the range, force, speed and co-ordination of the movements needed to achieve appropriate breathing, phonation, resonance and articulation for speech (Royal College of Speech and Language Therapists 2006). Speech may sound flat, slurred, nasal or have a jerky rhythm; pitch, loudness and breath control can also be affected.
Dyspraxia of speech is different from dysarthria as it is not caused by muscle weakness or sensory loss but is a disorder of initiating and sequencing purposeful/voluntary movement. Verbal expression may be hesitant with sound substitutions, for example saying ‘tup of tea’ for ‘cup of tea’.
Dysphonia is a voice disorder and may be related to disordered laryngeal, respiratory and vocal tract function and reflect structural, neurological, psychological and behavioural problems as well as systemic conditions (Mathieson 2001).
Anatomy and physiology
Language
It is now recognized that many areas of the brain are involved with language processing and the complex relationship between structure and function is not fully understood. Distortion and/or compression can occur at some distance from a problem (like a primary or secondary tumour). This means that any consequent cognitive and language impairments may have no direct relationship with the location of brain tumours (Gaziano and Kumar 1999, Gehring et al. 2008, Meyer and Levin 1996, Murdoch 1990, Scheibal et al.1996).
Speech
Speech (dysarthria), voice (dysphonia) and swallowing (dysphagia) can be impaired by any brain tumour or head and neck cancers involving the ventricular system, brainstem, cerebellum and cranial nerves (V, VII, IX, X, XI, XII). The management of swallowing difficulties is covered in Chapter 8.
Related theory
The brain is the organ of the body that is, above all others, linked with our sense of self. The importance of effective communication is considered at the beginning of this chapter and this need becomes more apparent with any communication disorder. Speech and language shape our thoughts, and language is necessary to make sense of or give meaning to our world. It is the currency of friendship (Parr et al. 1997) and is intrinsic and essential to our well-being. Its value and complexity may not become apparent until it is disrupted.
One of the key issues for patients with aphasia (disruption of language processing) is when we expect them to make sense of their disease, its treatment and management options. To do this, they need to use the very medium that is damaged – language. This may have an obvious or more subtle impact upon how the patient’s psychological, emotional and social needs are met.
When patients have difficulty communicating, their sense of identity can become fragile and may be further undermined when they are in a hospital. Understandably, in this environment, the focus is on their medical diagnosis, prognosis, treatments and side-effects. Facilitating their communication strengths allows us to help them understand, as well as supporting, acknowledging and respecting their individual needs.
Barriers to communication
Poor memory: delayed language processing can further compromise short-term memory problems.
Reduced concentration and short attention span: acute post surgical; during and after radiotherapy treatment to the brain.
Distractibility: increased sensitivity to background noise or visual distractions.
Generalized fatigue: already using extra energy to process language, it becomes too effortful to chat.
Previous communication style and communication needs.
Evidence-based approaches
Communication is a neurological function and the speech and language therapist has a key role in the specialist assessment and management of disorders/disruptions