Helping People with Progressive Memory Disorders »

Chapter 6: Communication Disorders Aphasia, Agraphia, and Alexia

Diseases that affect the brain may cause problems in talking, understanding speech, reading, and writing. Aphasia refers to difficulties in the ability to understand or express oneself through speech. Aphasia commonly occurs in people who also have agraphia and alexia. Agraphia refers to difficulties with writing ability. Alexia refers to difficulties with reading ability. These problems occur most often with Alzheimer's disease and strokes but may be seen with other forms of dementia. Damage to the left side of the brain (the left hemisphere) in most people who are right-handed results in these kinds of problems. Some examples of communication problems include:

Aphasia, agraphia, or alexia may appear as the only difficulty. This difficulty may result from a single stroke. It may result from some kind of ongoing decline in brain cells that may affect only one function. For example, at first progressive aphasia may affect only speaking ability for a long time. After several years, it may affect understanding while memory may remain excellent. More information is available about progressive aphasia through a local neurologist or the National Aphasia Association, 1-800-922-4622 (see address in Appendix Directory).

SPEAKING
Typically, it is hard for people who have Alzheimer's disease to name objects. For example, when they try to name an object, they might be able to tell what it does, but not able to say its name. Sometimes it is easy for them to name the whole object but hard for them to name part of an object. For example, they might know what to call a pen, but might not be able to say what to call the point of the pen or the cap of a pen.

Circumlocution
It may be hard for patients to find words. Instead they may describe the word they cannot remember. This roundabout way of talking is called circumlocution. For example, instead of saying, "I need a pen," they might say, "I have to have one of those things you write with...the one that has ink

Wrong Words
Many people with Alzheimer's disease might also make other mistakes, such as using the wrong word. For example, they might use the word pencil when they mean crayon. They also might say the wrong sound. Instead of saying "pen," they might say "den."

Or they might make up a new nonsense word (without any meaning), called a neologism. Instead of saying "car," they might say "flemer" (not a real word).
As the disease gets worse, people make more mistakes when they speak. They may ramble or make little sense when they talk. As time goes on, they may stop speaking all together.

Understanding Speech
At first people with Alzheimer's disease understand speech well. But as the disease gets worse, they have more and more difficulty understanding. First, it may be hard for them to understand sentences with many parts. An example of this type of sentence is, "Put away all the groceries and leave out the vegetables for the salad, but first put the butter in the refrigerator."

It may also be hard for them to under-stand sentences that have difficult grammar, for example, "Are you sure you didn't want to see him before he went out for the evening?"

As the disease gets worse, they might not understand short sentences like, "Bring these carrots to the table." Later on, the patients may be unable to under-stand single words, such as "carrots."

Watching the eyes of the person with dementia will help the caregiver to know what is understood. A blank, empty look may mean no understanding. Eye-to-eye contact keeps the attention. A smile with eye-to-eye contact may mean focused attention. This type of look may vary in meaning. It may mean, for example, interest in a topic being discussed, a little understanding, a feeling of comfort, or agreement and a willingness to do the activity. For example, in response to a request to get the newspaper, a smile with eye contact may be the sign of agreement although the caregiver may need to point out the newspaper and start the person in the right direction.

READING
Reading comprehension also declines as Alzheimer's disease progresses. Gradually there is less and less understanding of written words. Even if they can read the words aloud, they might not under-stand the meaning. Simple, short stories will be understood better than long and difficult material. When a person can no longer read words, looking at pictures may bring some pleasure.

WRITING
Writing ability declines as Alzheimer's disease gets worse. The person may struggle to write reports at work, letters to friends, or notes in a personal diary. They may write the wrong words or misspell words. Next they may have a problem writing short notes or taking messages over the telephone. Eventually they may get to the point where they can-not sign their name on a greeting card.

WAYS TO HELP COMMUNICATION

Some ways to help communication were identified in the previous chapter, which focused on memory. In the following pages we discuss the best conditions for communication: (1) the best place for communicating, (2) the best state of mind to express oneself and understand others, and (3) the best way to talk to someone with a communication disorder.

The Best Place
When you are talking with a person who has a hard time communicating, it is important to choose the best place.

The Best Place is:

Quiet - It is hard to understand speech when there is a lot of noise. When talking to people with dementia, try to make sure everything is quiet. Remember that people with dementia may have a hard time understanding and are easily distracted. For example, turn down loud music, shut off the television, stop the dishwasher, and avoid other household noises when talking with these people.

Peaceful - Peaceful surroundings might also aid the patient's under-standing. By removing distracters, such as playful pets, the focus can be on the task at hand. By moving away from the distracters, paying attention and understanding become easier.

A room divider, a folding door, a curtain hanging from the ceiling, or a folding screen around the "work area" or activity area creates a smaller, more private space for those easily distracted. The room divider or screen absorbs some of the extra sounds, especially in a large room with echoes. The privacy wall blocks out some of the visible distracters, such as other people in a dining room, so a person can focus on speaking and understanding.

A Small Group - People with dementia communicate best when face-to-face with one other person. When talking to people with Alzheimer's disease in a group, keep the group as small as possible, address the person by name, and use eye contact. Have only one conversation going on at a time.
Provide help when the topic of conversation changes. For example, "Tom, now we are talking about Sam. Sam has the red car. Sam played the clarinet last night at the concert."

The Best State of Mind
The best state of mind is to be rested, calm, adaptable, and open to new possibilities with a positive attitude. Usually when people are tired, troubled, or upset, they cannot understand or remember as well. People with severe dementia will pay attention better if first their basic needs such as hunger, thirst, exercise, or toileting have been met.

The Best Way to Talk
There are many ways to say the same thing. It is important to speak simply so that the person can understand. The following hints will help make speech simpler and perhaps better understood.

To keep the person's attention, it is helpful to:

Use Everyday Words - For example, instead of saying, "Cultivating a garden is so demanding," say "Weeding is hard." It is much easier to understand.

Use Exact (Concrete) Words - Avoid abstract words, which can be confusing. Abstract words refer to things such as feelings or a state of mind. Concrete words are words that can be sensed (seen, felt, heard, smelled, or tasted). The sentence, "Jim walked to the store" has concrete words. The concrete words are "Jim" and "store." This sentence talks about action that can be seen directly.

A more difficult sentence, "Jim wondered about his anger" has two abstract words ("wondered" and "anger"). Although the anger may be seen, "wondered" may be hard for someone with Alzheimer's disease to follow and understand.

Limit Describing Words - For example, do not say, "We need to walk down Frasier Street to the new big discount furniture store." Instead say, "Let's walk to the store." This sentence has fewer extra words for a person to listen to and thus is easier to understand. When near the store, it may help to point to the object and use one describing word at a time, such as, "There is the new store. The store sells tables."

Do Not Use Metaphors (Words Expressing a likeness) - For example, do not say, "Let's walk like a bear is chasing us." Instead say, "Let's walk fast." This last sentence is much easier to understand.

People often use analogies or sayings to make a point. Saying "Being a good friend is like being a good gardener" may confuse a patient with dementia. They may not be able to connect the relationship between friend (caring for someone else) and gardener (caring for plants). The sentence, "You are a good friend," is much easier for them to understand.

Be Direct - Do not say, "Would you like to go to the store?" Instead say, "Let's go to the store." This last sentence is direct and less likely to be confusing.

Use Short Sentences With Simple Grammar - It is helpful to use sentences with a subject, verb, and object. For example, in the sentence "Jim ate candy"-"Jim" is the subject, "ate" is the verb and "candy" is the object. People with dementia may tire easily and may not be able to follow a long sentence.

Do Not Use Pronouns When Using More Than One Sentence - For example, the sentences, "Jim ate candy. He got sick." contain "he" and may not be understood. It is helpful to repeat the names, "Jim ate candy. Jim got sick." without the pronoun "he".

Speak Briefly - Say one thing at a time. For example, do not say, "Jim ate too much candy, had an upset stomach, was sick for a while, and is sleeping in bed now." Instead, "Jim is sleeping" is easier to understand. When talking about actions with many steps, give the correct order. For example, do not say, "Before coming home, Jim went to the store." Instead, put the sentence in the order in which something happened. For example say, "Jim went to the store. Then Jim came home."

Be Patient - Speak slowly and wait between sentences. Some people with dementia need extra time to express their words. To give such people enough time, it may help to remember the 15-second rule. The listener should count silently to 15 to allow enough of a pause for the slower person to respond.

Speak Slowly and Clearly - A person with dementia may also be hard of hearing. Most of the time, shouting does not help the person hear better. A helpful way to communicate with hearing impaired persons is to speak each word slowly and clearly. The person with hearing loss may miss words that are shouted. Instead they may sense a strong emotion, misunderstand, and think you are angry.

Repeat Sentences, Word for Word - People will often understand if given a second or third chance to hear it. If repeating the same words slowly does not help, try using different, simpler words to state the message. If "Let's sit down for breakfast" does not make sense, try "Let's eat" or "Breakfast" or "Hungry?" as you point to the food. Repeat the beginning message so the speaker does not have to start over. When a message is hard to under-stand, repeat what was received to help the speaker move on to the next part of the message. Never respond with "What?" or "Huh?" With each interaction, say the part that was received so that after several turns, the speaker completes the entire message. For example:
Speaker: "Lunch. "
Caregiver: "Lunch. You are asking about lunch..."
Speaker: "What...lunch."
Caregiver: "What are we eating for lunch?" or "What do you want for lunch?"

Try Different Ways to be Understood - Use nonverbal ways to communicate such as:

Check for Understanding. Ask the person with dementia to explain what was just said in their own words. People with dementia might be able to repeat without understanding. Some people may answer "yes" or "no" to everything. If all "no" answers are given, check with a question that should be answered "yes." If all "yes" answers are given, try a question that should be answered "no."

TIPS TO HELP PEOPLE WITH DEMENTIA COMMUNICATE

The person with mild memory loss may find it helpful to:

  1. Say it or write it.
  2. Think of similar words and start saying or writing them until the correct word is found.
  3. Think of the first letter and say it aloud or write it down.
  4. Think of the function and other activities linked with the word and say these aloud or write them down.

People with Alzheimer's disease may have problems making themselves understood by others. To help them express their thoughts and feelings, try teaching them several strategies to get the message across.

Ways For People With Dementia To Communicate Better
The person with severe memory loss may find it helpful to:

  1. Point to an object or person.
  2. Act out the situation or need.
  3. Use a different tone of voice or pace of words to show different meanings.
  4. Use facial expressions to show what is meant.
  5. Write or draw.
  6. Use index cards with common words or phrases or pictures they can point to. (These may be made by the family or bought in sets from stores serving people with special needs.)

If the person with dementia is not able to use these six suggestions, the caregiver may try another approach.

Direct, Simple Questions
It might help to break many choices down into simple steps or choices needing yes or no answers. The caregiver could ask questions that need only a yes or no answer, head nods, or pointing.

For example, the person with dementia may be unable to answer the question, "What do you want to eat?" Instead, ask the question, "Do you want to eat meat?" Then wait. Or ask, "Do you want chicken?" Or try pointing and asking, "Do you want this leg of chicken?" Use step-by-step questions that need either a "yes" or "no" answer.

Humor
Above all, keep a sense of humor. In difficult times just smile, take a break, and wait. A few minutes later may be a better time to do the activity.

CHAPTER SUMMARY
Diseases that affect the brain can lead to decline in speech comprehension or expression (aphasia), decline in writing ability (agraphia), and decline in reading ability (alexia).

Speaking and Understanding Speech
People with aphasia have difficulty speaking and understanding others. At first they may be unable to recall an exact word or person's name, talk in a roundabout way (circumlocution), substitute wrong words in an expression, or use the right word but with a wrong speech sound. Sometimes people with aphasia make up new words, called neologisms, that are not true words. People with dementia slowly become able to understand only simple, brief communication. As communication becomes harder for them, they may slowly withdraw from interactions with others.

Reading
As reading ability declines, the person gradually has less understanding of written material and may be happy just to look through picture books.

Writing
Problems with writing often show up first as inability to write stories or letters, as misspellings, and eventually the person may be unable to write a signature on a greeting card.

The Best Conditions for Communication

The best conditions for communication:

  1. The best place is quiet and peaceful with the smallest group possible.
  2. The best state of mind is being rested, calm, and positive.
  3. The best way to talk is with simple, clear, brief, and direct words.

Nonverbal helps to communication include using hand signals or gestures, pointing, drawing or showing pictures, and writing words. However, be careful that these do not cause distractions. Pointing may distract the person who is trying to listen to spoken words. Do one thing at a time. First try speech.

If repeating the spoken message does not work, try to point. First smile at the person. Be sure to get the person's attention before pointing. Use a strong arm movement to point to keep the person's attention on the task.

It is important to check understanding. The person with dementia could explain what they just heard or they could respond with a "yes" or "no" to direct questions about the communication.

Tips to Help People With Dementia
Suggestions to help people with dementia communicate better include writing, drawing or pointing, acting, or changing voice tones or face expression to show the meaning. Sometimes it helps to use index cards as word-cards or picture cards.

The Next Chapter

Go back to the index.

Material taken from

"Helping People with Progressive Memory Disorders: A Guide For You And Your Family, 2nd ed." (University of Florida Health Science Center). Used with permission from the authors: K. M. Heilman, MD, L. Doty, PhD, J. T. Stewart, MD, D Bowers, PhD, & L. Gonzalez-Rothi, PhD. (1999).

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College of Public Health and Health Professions, University of Florida