The art of communicating with stroke patients
Teach aides how to meet the challenge
Home care aides often find it difficult and frustrating to deal with patients who have trouble speaking because of a stroke, head injury, or brain tumor.
The disorder, called aphasia, affects about one million people in the United States. Aphasia impairs communication, including speech, writing, and reading. It occurs after brain damage, most often the result of a stroke.
An Alabama education manager found that home health aides wanted to know more about what happens to people who have had strokes, and they were particularly interested in understanding the problem the patients have with speech. So she created an inservice exploring the topic.
"One of the questions they asked was they wanted to understand why patients are different after a stroke," says Allyson Baker, RN, education coordinator for Decatur (AL) General Home Health Services. The hospital-based, full-service agency serves four counties in northern Alabama.
"Several aides commented that they have patients who get very frustrated and angry, and I just helped them understand that it’s not just you that they’re frustrated and angry with, but it’s with themselves," Baker says.
The agency’s aides said they learned a lot from the inservice on stroke patients, and they have asked for follow-up courses on aphasia and paralysis, Baker says.
How to design an inservice
She and two experts on aphasia offer these guidelines for creating an inservice on aphasia and stroke patients:
1. Define aphasia in stroke patients.
Baker showed aides a videotape about stroke patients from the American Heart Association during the first inservice. (See aphasia resource guide, inserted in this issue.)
Aides were given hand-outs from the National Aphasia Association in New York City during the follow-up inservice on aphasia, which was taught by speech therapist Paige Harrelson, MS, CCC-SLP. (See aphasia fact sheet, p. 138.)
Harrelson explained that aphasia is a loss of language that can affect how the patient hears and expresses words. "It’s almost like if they were in a foreign country they might pick up some words, but they might not understand all of them," she says. "Or it might be like static, where they get a word and then there’s more static."
When words fail
Other aphasic patients might understand everything, but they may be unable to respond, Harrelson says.
"They’ve lost the language to describe it or name it," she explains. "They can’t find the right words, or they might not be able to say anything, or they might make up a word."
For example, an aphasia patient might say the word fork when he or she meant to say spoon. Or the word spoon could become stoon.
Instead of saying, "Put the car in the garage," the patient might say, "Put the car in the house." Or it could become, "Put the tar in the garage." And some patients might make up a word to replace the one they can’t remember, saying things like, "Put the snagel in the garage."
2. Describe the two types of aphasia.
• Fluent aphasia: Patients who have fluent aphasia can speak, but their words might not make sense, Harrelson says. "If you weren’t paying attention to them you wouldn’t think anything was wrong," she explains. "They use a lot of filler words and don’t get their point across. They say a lot and it sounds normal, but there is no content to it."
• Nonfluent aphasia: These patients struggle to get the words out, and they must search to find the right ones, Harrelson says. "They have a lot of hesitation, a lot of pauses searching for the right word."
3. Show aides how to communicate.
"Probably the biggest thing I told the aides was to remember that it’s not a loss of intelligence, and they still have to treat the person like the person can understand them," Harrelson says. (See dos and don’ts on communicating with people who have aphasia, p. 139.)
Aides can help the patient understand them better with the following actions:
• Speak slowly while looking directly at the patient. Harrelson says this allows the patient to take cues from facial gestures.
• Break up sentences into one thought at a time. "Instead of saying, Let’s get over here on the bed so we can take a sponge bath,’ break it up into short, easy instructions," Harrelson suggests.
The better way to communicate would be to say each of these sentences slowly, giving the patient time to understand and react:
"Let’s stand up."
"Let’s walk over to the bed."
"Let’s sit down."
"We’ll wash your face."
• Use gestures when talking. "When you’re saying, Comb your hair,’ use the motion of combing your hair," Harrelson says.
4. Discuss the patient’s emotional changes.
Baker tells aides to allow stroke patients to ventilate their anger and frustration: "We don’t want them to abuse you," she told the aides. "But they can’t help sometimes what they’re saying."
Frustration is a major problem for both caregivers and aphasia patients, says Penny Montgomery, resource director for the National Aphasia Association. Montgomery became involved with the 10-year-old organization after her husband had a stroke.
"It takes a lot of patience and maintaining a sense of humor," she says. (See story on working with aphasia patients, below right.)
Filling the gaps
Montgomery says aphasia patients might not know what a particular word means, so they are scared and their frustration builds up. This problem becomes worse in the months after the stroke because patients worry they might not get better.
One aide at Decatur General Home Health Services discussed a patient who cursed all the time, causing the patient’s wife to continually apologize for him.
This is common, Harrelson says. "A lot of times, if they’re not able to talk, they’ll automatically say curse words or come out with "No!" really loudly because those are automatic responses that they didn’t have to think about."
5. Reduce background noise in the patient’s home.
Montgomery says aides and caregivers should be sensitive to any outside noises when speaking with an aphasia patient.
"If you’re trying to have a conversation, it should be one-on-one," she says. "People who have acquired aphasia have to concentrate so hard on what they are trying to say that every other noise has to be silent. So turn off the radio, television, and things like that."
6. Explain that aides should ask only simple questions.
It’s important to stick to "yes" and "no" questions when a person first acquires aphasia, Montgomery says. "The details are very hard for people with aphasia, so if you ask a lengthy question, you’re not going to get an answer."
7. Tell aides that progress might be very slow.
Baker says her agency’s aides were curious about why some stroke patients got better and others did not. So she explained that it depended on which part of their brain was affected by the stroke and how severe the stroke was.
"I told them that sometimes right after the stroke, if the patient comes right home instead of going into a rehabilitation facility, the patient might not make any progress," Baker says.
"Then several months down the road when the brain has had a chance to rest, the patient might be able to do a little more."
8. Advise aides to report any changes in the patient.
If the patient starts to attempt speech when he or she hasn’t spoken before, then the aide should notify the nurse who is responsible for that patient, Baker says. Aides also might notice that a stroke patient has begun to help more when the aide is turning or transferring the patient.
9. Instruct aides to report any problems with patients or families.
Sometimes the families of aphasia patients will ventilate their frustration by complaining about the aides. Baker tells aides to let their supervisors know if there’s a problem.
Also, aides should keep an eye on their own frustration levels when dealing with stroke patients. "Sometimes it’s necessary to switch aides in that home and give them a break," she says.
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