Clinical Evaluation & Observation
Is it dementia? Is it aphasia? Is it apraxia? Is it dysarthria? A combination of two or more?
Or is it all of the above?
I ask myself that question frequently, and it can take a careful clinical evaluation and observation during therapy to determine what is truly the most specific cause of communication problems. When patients arrive and their History and Physical (H&P) reports a diagnosis of dementia, many professional assume that communication deficits are a result of cognitive deficits, and they very well might be. Let us suppose that a patient went to the hospital with an episode of altered mental status (AMS) and a urinary tract infection (UTI). The patient also has a diagnosis of dementia and of transient ischemic attacks (TIAs). The hospital noted that the patient is a very poor historian, does not answer questions, and is oriented to person only. The patient is admitted to the SNF, and nursing staff assume that all of the communication deficits are related to cognitive deficits and that the patient simply cannot understand questions and directions.
A careful clinical exam, including components such as Brief Cognitive Rating Scale (BCRS), Global Deterioration Scale (GDS), Allen Cognitive Levels, the Ross Information Processing Assessment,- Geriatric (RIPA-G) and a speech and language sample should reveal much more about the patient's ability to communicate and that is our job: to get to the specifics of the communication disorder, treat the patient, and educate the patient and the staff so that the patient can communicate and participate in daily activities.
Patients with apraxia might be so slow to respond that the untrained person might assume that they just do not know the answer. Patients with aphasia might say it is November when it is May. Patients with dysarthria may have articulation and intelligibility deficits that result in either the patient giving up on responding, or the listener abandoning questions because they do not understand the problem. Speech and language disorders are often misinterpreted as cognitive disorders.