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Fall 2010Speech Deficits in Parkinson’s Disease Despite speech’s progressive impairment over the course of Parkinson’s disease, early intervention can help improve PD patients’ communication skills. Parkinson’s disease (PD) affects between 500,000 and 1 million people in the United States. Approximately 50,000 to 60,000 people are diagnosed with the disease each year, and it is the 14th leading cause of death in the United States. It reduces life expectancy by three to nine years. The estimated cost of providing treatment for an individual with PD for one year ranges between $1,000 and $6,000 for drugs alone, to surgical intervention that could cost upwards of $25,000, to the cost of placing someone with PD in an assisted-living or skilled nursing facility, which can cost as much as $100,000 per year, according to the Michael Stern Parkinson’s Research Foundation. The progressive deterioration patients and their loved ones experience can be physically, emotionally, and financially devastating. By the time the disease has run its 10- to 25-year course, most individuals with PD will have experienced impairments in their motor skills, communication, social participation, swallowing, emotional health, and cognition. According to data on the Parkinson’s Disease Foundation website, 89% of those who experience PD develop speech impairments. The typical configuration of speech changes associated with PD is known as hypokinetic dysarthria. The characteristics that present in elders exhibiting hypokinetic dysarthria may include limited pitch range or intonation, reduced emphasis of stressed syllables and words, reduced loudness, decreased accuracy of articulation, rapidly spoken phrases separated by extended pauses, and a raspy voice.1 This should not be confused with language impairment, in which an older adult may exhibit difficulty with vocabulary, grammar, and word order. It is as though the neuromotor system can’t keep pace with the thoughts the individual wants to express. Also, the emotional expressiveness that most of us take for granted—that is, the ability to change pitch or loudness to emphasize our opinions—becomes considerably flattened in the dysarthria accompanying PD. Does it come as a surprise that those who suffer from these impairments frequently withdraw from social contact? Communication Challenges Scientists have also evaluated PD speakers’ perceptions of their communication impairment as well as caregivers’ perceptions. Among the sentiments reported by the PD speakers were observations about the considerable effort required to produce speech over the course of conversation. They noted the challenge of coordinating articulation, breathing, and voice and the resulting difficulty with joining in and maintaining a place in a conversation. Distractibility was also reported. Older adults with PD noted that the slowed ability to deliver their messages sometimes resulted in their inability to completely express a thought. Some speakers actually reported that they had forgotten what they had planned to say after having spoken a portion of their message.4 PD speakers “sense they have lost control in communicating, are less confident, find it difficult to get their message across, with consequent frustration, feelings of inadequacy, and sense of loss of independence.” Caregivers’ ratings of their partners, when compared with the PD patients’ self-ratings, judged the patients’ communication impairments as less severe than did the patients themselves.5 Positive Intervention Early referral for speech and language evaluation is recommended upon a PD diagnosis, even before significant changes in speech have been observed. This allows the patient and his or her spouse or caregiver to begin considering the patient’s wishes related to potential communication changes. It allows for establishing a baseline and creating a recorded sample of the patient’s communication for later comparison. Speech changes have often occurred by the time someone is officially diagnosed with PD. One group of researchers expressed the need for early intervention this way: “There ... exists an argument for early referral for evaluation of communication changes extending to psychosocial impact, and not focusing narrowly on voice and speech alteration. If one waits until these become obvious, the person may well have developed such feelings of loss of control and confidence that these become significant added barriers to improvement in speech.”5 Contact with a speech-language pathologist allows a patient and support persons to obtain information about the disease process and potential communication difficulties. The involvement of a communication partner is essential. This person will learn to provide feedback, reinforce practice recommendations, and provide emotional support throughout the disease course. A partner can also learn to educate other listeners in the PD patient’s social circle. The demands of the support person’s role must not be underestimated; awareness of this person’s coping skills should be observed. A skilled speech-language pathologist will notice the necessity for involving additional professionals to meet the needs of the caregiver as well as the patient. The speech-language pathologist will ideally involve spouses, families, and other significant people in the PD patient’s life. Training can be provided for PD patients and their significant others to negotiate their approach to conversation: Does the patient want the listener to finish a sentence when he gets stuck, or would he prefer that the listener wait for him to complete the thought? These dyads can be coached to develop and appreciate their shared sense of humor and utilize it when light moments are in short supply. As a clinician facilitates a patient’s expression of feelings about the challenges he or she is facing, partners can gain a better understanding of the patient’s reactions to various situations and can be encouraged to provide necessary support. Communication, after all, is a shared experience. Miller et al concluded, “Parkinson’s disease speakers without a carer recorded more difficulty getting their message across, being more unclear, more self-conscious when communicating, and less valued and quieter.” Another advantage of early referral to a speech-language pathologist is the introduction of information about the potential communication impairments that develop as the disease progresses. Patients and their support persons can begin discussing their desires and intentions for coping with the impending changes. Some factors to consider in treatment planning phases are the individual’s willingness to participate in regular communication training sessions and the degree to which the patient is willing to commit to regular, sometimes intensive, independent practice. In some cases, as the communication impairment advances, using assistive devices may be considered. It is beneficial to consider this eventuality prior to when decisions need to be made. A review by Harrison N. Jones, PhD, explains that neurosurgical and pharmacological treatments are not reliable independently as treatment for PD speakers’ reduced ability to express emotion through speech. Research supports the effectiveness of training in the use of specific techniques to modify one’s speech production. Perhaps the most widely recognized treatment for the dysarthria manifest by patients with PD is known as Lee Silverman Voice Treatment. Other treatments that have been effective with PD patients include biofeedback, using delayed auditory feedback, and various approaches to train a patient to reduce speaking rate.6 Identifying Appropriate Options For some, a portable voice amplifier may be the ticket. Anthony’s profession, for example, involved extensive public speaking. Socially, he’d always been the life of the party. When dysarthria related to PD became increasingly intrusive, he considered amplification to ease his ability to address small groups. Aside from recommending the evaluation of communication skills and subsequent training for patients and caregivers, what suggestions might healthcare providers offer? Education, for one. Within a community where there are speakers with PD, it is helpful for others to understand these speakers’ needs and challenges. Healthcare practitioners may suggest, “Charlie might need some extra time to finish his sentences; please be patient.” Provide communication experiences that are rewarding for PD speakers. If a patient with PD attends a scheduled lecture, for example, someone may be encouraged to help him prepare a list of questions for the speaker in advance. Reading may be far easier than formulating on the spot. Supporting maintenance of a positive attitude is key. Facilitating participation in desired activities can help a PD patient’s outlook. Joe had been a skilled bridge player, but then it became too challenging for him to complete a game. He and his wife have developed a tag team approach. He begins the hand and his wife takes over after 10 or 20 minutes when his attention and energy have flagged. Joe, his wife, and their friends continue to enjoy these social occasions. Angela refused to succumb to the depression accompanying PD that she learned about in her research. She described her active decision to maintain a positive attitude about her abilities. She still operates her own business more than a decade after she was diagnosed with PD. PD speakers often must learn to conserve their energy for a particularly demanding social occasion. If there’s a gathering scheduled in the evening, practitioners can advise limiting conversation earlier in the day for optimal communication ability. A healthcare advocate can be invaluable, for example, by helping the person with PD draw up a list of questions prior to a medical appointment and then accompanying the patient to the office visit. The patient and the advocate should discuss who will ask the questions, according to the patient’s desires. They may want to take a voice recorder to capture important instructions or be sure to request written recommendations. Support groups for people with PD and their families are often valuable resources, as are movement/exercise groups. Nina Browner, MD, medical director of the National Parkinson Foundation Center of Excellence at the University of North Carolina at Chapel Hill, suggests that regular exercise practiced by patients with PD is likely to contribute to their self-esteem and sense of ability to influence their health. Besides the benefit inherent in physical movement, the organized group experience usually includes support and encouragement provided by other participants. There is no formula for developing an appropriate treatment program for a PD patient with dysarthria. Each individual’s configuration of speech changes, degree of impairment, support network, and emotional status affect intervention choices. Even the most vibrant individuals who had relied on superior communication skills for a living struggle with the loss that speech changes create. Early referral for speech and language evaluation and treatment is the key to establishing a plan for optimizing communication over the long haul. This professional support, in addition to establishment of a network of family and friends who accompany the PD patient on his or her journey, is the foundation for enhancing one’s continuing relationships with spouses, friends, and members of one’s community. — Deborah Crabbs MacDonald, MS, CCC-SLP, is a speech-language pathologist at Berkshire Medical Center in Pittsfield, Mass.
Understanding Dysarthria Pay close attention to all of the details, beyond the words spoken, that contribute to the meaning of the communication. If you ask a friend or colleague to try the same sentence production task, you’re likely to hear a slightly different inflection pattern from your own. Notice how the respective personality shines through. Now, go ahead and say the same sentence with a monotone delivery: don’t emphasize any word; don’t vary your pitch. Do you think someone listening to that version could tell how you feel about missing work? It is amazing how much information is conveyed by rhythm and variations in the pitch and relative emphasis created by the voice.
References 2. Jaywant A, Pell MD. Listener impressions of speakers with Parkinson’s disease. J Int Neuropsychol Soc. 2010;16(1):49-57. 3. Pell MD, Cheang HS, Leonard CL. The impact of Parkinson’s disease on vocal-prosodic communication from the perspective of listeners. Brain Lang. 2006;97(2):123-134. 4. Miller N, Noble E, Jones D, Burn D. Life with communication changes in Parkinson’s disease. Age Ageing. 2006;35(3):235-239. 5. Miller N, Noble E, Jones D, Allcock L, Burn D. How do I sound to me? Perceived changes in communication in Parkinson’s disease. Clin Rehabil. 2008;22(1):14-22. 6. Jones HN. Prosody in Parkinson’s disease. Perspect Neurophysiol Neurogen Speech Lang Disord. 2009;19(3):77-82.
Provider Perspective • Encourage PD patients to seek speech and language evaluation soon after diagnosis. • Help PD patients obtain information about the disease process and potential communication difficulties. • Promote identification of a communication partner who can gain an understanding of the patient’s reactions to various situations and provide necessary support. • Anticipate likely communication challenges and be proactive in suggesting strategies that will accommodate the patient’s speech deficits. |
