Creative Strategies for Improving Speech

Communication disorders that accompany progressive diseases affecting the nervous system, such as Parkinson’s disease or amyotrophic lateral sclerosis (ALS), differ from aphasia. These disorders involve the speech production system rather than language production and usage. Dysarthria is the broad descriptor of symptoms that involve changes in any or all of the following aspects of speech: voice, respiration, resonance, prosody (rhythm and tonality), and articulation. The speech of an older adult with dysarthria may be slower or faster than normal, the volume may be low, there may be a more nasalized quality, pronunciation may be poor, or the delivery may be monotone. In addition, elders with dysarthria often experience difficulty coordinating breathing with speech. Typically, several of these characteristics are involved in an individual’s speech pattern when affected by dysarthria, and most of these symptoms worsen as the disease progresses. In some cases, an augmentative communication support becomes necessary as speaking becomes a decreasingly successful means of expressing thoughts, wishes, and needs.

The communication partner’s role—as an important element in the feedback loop—becomes key early in this progression. The partner becomes the older adult’s functional reminder to monitor his or her own speech production. In response to training provided by a speech-language pathologist, the communicators can develop a system for signaling to the dysarthric speaker that revision is necessary. It could be as simple as a request to repeat, which triggers the implementation of strategies developed to improve speech intelligibility. When partners are included in the treatment, they practice conversation with the training clinician’s supervision. Partners become familiar with the specific modifications an individual has been trained to use to improve speech intelligibility and can provide cues to the elder to utilize them. With such a system in place, partners can avoid getting caught in an endless loop of “What did you say?” followed by a repetition of the same unintelligible message.

Case in Point

Here’s an example illustrating the ideal use of partners. Phyllis, a woman in her late 70s, has been diagnosed with ALS. Her speech has been deteriorating gradually for about one year following her first visit to the outpatient speech therapy clinic. With her breathing obviously affected, Phyllis requires oxygen at all times. She takes frequent labored breaths while speaking and sometimes fails to clearly mark the spaces between her words. She frequently abbreviates multisyllables. Sometimes she speeds her speaking rate in an attempt to squeeze the desired words into one breath. Her volume is sometimes low. In the quiet setting afforded by the speech clinic, it’s easy to understand nearly everything Phyllis says. However, her home setting with its usual ambient noise is larger and more open. Conversation at home often involves more than one person in addition to Phyllis. She usually tires by day’s end, which causes her speech intelligibility to suffer.

Phyllis lives with family members and frequently spends time with other family and friends. At least one family member accompanies her to each treatment session. She first learns to control her breathing for optimal support of speech. When she masters such control to the level of accurate self-critique, she addresses speech pacing and articulation. She then practices reading sentences that she and the clinician can see to her family member. The partner then parrots back what he or she has understood. Phyllis either says, “You got it!” or practices specifically trained revision strategies to sharpen the message. As she becomes increasingly successful, the practice moves to longer sentences, summarizing paragraphs, and eventually conversation. The speech pathologist observes each phase, coaching both Phyllis and the partner of the day. She reminds Phyllis about the finer points of breath control and reminds the partner about skillful feedback. She also suggests to Phyllis and her partner that because it becomes too taxing to converse later in the day, evenings are not the best time to receive visitors. It’s also important to consider how a visitor who wears a hearing aid should be positioned relative to Phyllis for optimal comprehension.

As the treatment course nears its end, the clinician shows Phyllis and her relatives several devices that may be worth considering as Phyllis’ disease progresses. It’s likely that speech will become considerably more difficult and intelligibility will suffer. She may eventually want to use a keyboard with electronic speech output capabilities to augment her own verbal expression. As a former office assistant, Phyllis has excellent typing skills. Her cousin listens to the spoken sentences Phyllis has typed into the device and easily comprehends them.

Phyllis enjoys communicating with several family members who have been trained to cue her appropriately when her speech becomes difficult to understand. They’ve learned to gently remind Phyllis what to do when she loses track of her breathing or syllable marking. And they’ll lend their support when the time comes for more treatment or to include a keyboard or other assistive device in her communication repertoire.