Types of communication disorders

There are several varieties of communication disorders that one may encounter in the practice of rehabilitation medicine, including (1) language disorders, (2) motor speech disorders, (3) cognitive-communication disorders, (4) deafness or hearing impaired, and (5) language barriers. The first two are briefly described next.

Language disorders are characterized by impaired comprehension or use of spoken and written language. The most common type of language-based communication disorders are classified as aphasias. Aphasia is a communication disorder that is acquired following brain insult. The primary cause of aphasia is a cerebral vascular accident (CVA). Aphasia hinders a person’s ability to comprehend and express language. It may also affect areas of the nervous system that are involved with information processing, memory, thinking, and other higher level language functions (eg, problem solving and abstract reasoning). The physiology of cortical function and its specialization is poorly understood. The exact differences between the right and left hemispheres are entirely understood. Language and fine motor function (eg, writing) are controlled by the language dominant hemisphere, the left hemisphere in 95% of right-handed individuals and 70% of left-handed individuals. Aphasias are common in stroke patients and those with brain injuries. It is estimated that approximately 1 million people in the United States are living with an aphasia and approximately 80,000 individuals acquire aphasia each year. Language disorders can also be seen in adults who failed to develop normal language because of impaired hearing or developmental disorders.

Motor speech disorders may result from neurologic diagnoses, including stroke, neuromuscular disease, developmental neurologic disorders, and obstructive neurologic lesions. Motor speech disorders can affect articulatory precision, voice, fluency, and resonance. Motor speech disorders can also differ in severity. Depending on the level of severity, motor speech disorders can significantly impact communication between the patient and the entire medical staff. Conditions that can lead to hindered communication include Parkinson disease, Huntington disease, and amyotrophic lateral sclerosis. In certain neuromuscular diseases, communication may progressively deteriorate until speech is no longer an available mode of communication.

Impact of impaired communication on patient safety

There are several characteristics and challenges common to hospitalized adult patients with communication disorders, which may have a major impact on their safety. These patients are faced with the challenge of effectively communicating personal needs and medical information to medical staff. After an acute stroke or traumatic brain injury, patients with associated cognitive impairment or aphasia are at risk for further preventable injuries. This is especially important in patients who show clinical signs of functional and cognitive impairment, but are unaware of their own physical limitations. They may not be able to adequately understand when physicians and nurses instruct them to ask for assistance with feeding, dressing needs, transfers, or toileting. This in turn can potentially lead to a fall within the room when the patient is alone.

Patients may also find it difficult to verbally express their symptoms to clinical staff. This presents a challenge for symptom management, such as pain. Obtaining an accurate medical history can be a challenge if the patient cannot provide key information. Healthcare professionals have to rely on close family members or charted documents from other facilities to obtain an accurate medical history. If this information is not correct, pertinent items may be missing, which in turn can affect the patient’s safety (ie, medication errors, allergic reactions, and inaccurate diagnosis).

Monitoring effectiveness of treatment for a disease can also be limited by the communication barrier. There may be situations in which patients with impaired communication have questions or concerns about a particular medical treatment. If the patient cannot communicate the concern, he or she may not be able to effectively participate in their plan of care. Patients may not understand the reason for taking a medication and therefore choose not to take it, or alternatively not take it in a safe manner. Without proper communication and expressed understanding between patient and physician, preventative or prophylactic treatment can become difficult, ineffective, and unsafe.

Patient care transition points, such as transfers between hospitals, services, attending physicians, and nurses, rely on discharge summaries and medical records for safety protection. Patients with communication disorders can have a difficult time describing their concerns and symptoms as they move through the healthcare system.

Assessment of the patient with communication disorder

It is important that the clinician evaluating a patient in a communication-vulnerable state obtain information from the patient’s family, caregiver, or other clinicians whom have cared for that patient in the past. Key information includes (1) appropriate communication strategies that they have used to communicate with the patient, (2) the patient’s daily routine, (3) sources of agitation for the patient, and (4) calming influences when the patient is upset.

The physical examination of the patient with a communication disorder should be performed in a quiet area. The clinician should use a calm tone of voice, face the patient, and make good eye contact. Appropriate communication aids used by the patient should be available (ie, hearing aids or prior augmentative communication systems). In many healthcare facilities, a Language Line may be available to facilitate translation to the patient’s native language if a personal translator is not available.

Key elements of the physical examination (focusing on communication, cognitive-communication, and swallowing) include (1) mini mental status examination; (2) cognition level of orientation and alertness, immediate and delayed recall, and executive function; (3) hearing and vision testing (including the use of eyeglasses and hearing aids); (4) speech–language communication of basic activities of daily living wants and needs; (5) swallow screen determining risk of dysphagia (described elsewhere in this issue); and (6) upper airway assessment.

The communication screen is very useful. This screen identifies the communicative status of the patient. If the patient can verbally communicate, key questions to consider include the following: (1) Is the patient’s speech intelligible? (2) Is the patient’s voice strained, hoarse, or hypophonic? (3) Can the patient follow one- or two-step commands? (4) Can the patient answer yes/no questions accurately?

If the patient cannot verbally communicate, key questions to consider include the following: (1) Can the patient follow one- and two-step commands? (2) Can the patient respond to yes/no questions accurately by gesturing or eye-blink tracking? (3) Is the patient able to write? (4) Is the patient able to see without restrictions? (5) Does the patient have volitional movement of fingers, head, and eyes?

If the patient is noted to be at high risk, he or she should be referred to a speech language pathologist for further evaluation and treatment interventions. Ideally, treatment strategies are individualized for each patient. Timely identification of communication impairments permits effective environmental modifications to be implemented by the medical team. This minimizes the risk of medical errors. Speech pathologists can also evaluate the patient for augmentative and alternative communication devices and training. The evaluation may include whether the patient can use facial expressions, body language, gestures, pointing to words or photographs, line drawing, picture or word communication boards, electronic communication systems, and integrated computer software that facilitates word processing and communication.